Healthcare Provider Details

I. General information

NPI: 1558395319
Provider Name (Legal Business Name): DUDLEY RAVEN BAILEY LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6521 SPANISH FORT BLVD
NEW ORLEANS LA
70124-4321
US

IV. Provider business mailing address

6521 SPANISH FORT BLVD
NEW ORLEANS LA
70124-4321
US

V. Phone/Fax

Practice location:
  • Phone: 504-571-5355
  • Fax: 504-389-4558
Mailing address:
  • Phone: 504-571-5355
  • Fax: 504-389-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA0959-01
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: