Healthcare Provider Details

I. General information

NPI: 1053327395
Provider Name (Legal Business Name): MAURA CARMOUCHE MIZE M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 PITHON ST
LAKE CHARLES LA
70601-5245
US

IV. Provider business mailing address

1130 PITHON ST
LAKE CHARLES LA
70601-5245
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-4212
  • Fax: 337-433-4234
Mailing address:
  • Phone: 337-433-4212
  • Fax: 337-433-4234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1075
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: