Healthcare Provider Details

I. General information

NPI: 1629332721
Provider Name (Legal Business Name): PEDIATRIC THERAPY OF LOUISIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 MAID STONE DR
LAKE CHARLES LA
70605-4030
US

IV. Provider business mailing address

4106 MAID STONE DR
LAKE CHARLES LA
70605-4030
US

V. Phone/Fax

Practice location:
  • Phone: 337-540-1861
  • Fax:
Mailing address:
  • Phone: 337-540-1861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateLA

VIII. Authorized Official

Name: MS. ALISA TRAHAN
Title or Position: OWNER
Credential: M.A., CCC-SLP
Phone: 337-540-1861