Healthcare Provider Details

I. General information

NPI: 1811161128
Provider Name (Legal Business Name): MARY MISTRETTA GAGLIANO LOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 MEDICAL CENTER BLVD
MARRERO LA
70072-3144
US

IV. Provider business mailing address

8128 FLORIDA BLVD
DENHAM SPRINGS LA
70726-7865
US

V. Phone/Fax

Practice location:
  • Phone: 504-347-0777
  • Fax: 504-349-9045
Mailing address:
  • Phone: 225-791-8666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberZ11548
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: