Healthcare Provider Details

I. General information

NPI: 1720990047
Provider Name (Legal Business Name): BAYOU ROOTS INTEGRATED CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 LOUISIANA AVE
LAKE CHARLES LA
70607-3044
US

IV. Provider business mailing address

PO BOX 143
LAKE CHARLES LA
70602-0143
US

V. Phone/Fax

Practice location:
  • Phone: 337-391-9976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ASHLEY ANTIONETTE MONTGOMERY
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 337-391-9976