Healthcare Provider Details

I. General information

NPI: 1992358949
Provider Name (Legal Business Name): ELIZABETH LOCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3347 DEBORAH DR
MONROE LA
71201-2150
US

IV. Provider business mailing address

3347 DEBORAH DR
MONROE LA
71201-2150
US

V. Phone/Fax

Practice location:
  • Phone: 318-729-1408
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8263
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: