Healthcare Provider Details

I. General information

NPI: 1477044832
Provider Name (Legal Business Name): IMPACT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6571 COLBERT ST
NEW ORLEANS LA
70124-2204
US

IV. Provider business mailing address

6571 COLBERT ST
NEW ORLEANS LA
70124-2204
US

V. Phone/Fax

Practice location:
  • Phone: 504-256-8714
  • Fax:
Mailing address:
  • Phone: 504-256-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL-255
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLA-4947
License Number StateLA

VIII. Authorized Official

Name: VALERIE R MARTINEZ
Title or Position: OWNER
Credential: BCBA
Phone: 504-256-8714