Healthcare Provider Details

I. General information

NPI: 1619464062
Provider Name (Legal Business Name): MEAGAN MOFFETT LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 HUDSON LN
MONROE LA
71201-6035
US

IV. Provider business mailing address

173 MOFFETT RD
JENA LA
71342-5747
US

V. Phone/Fax

Practice location:
  • Phone: 318-322-6500
  • Fax: 318-322-5118
Mailing address:
  • Phone: 318-316-5077
  • Fax: 318-322-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL-284
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: