Healthcare Provider Details

I. General information

NPI: 1609604784
Provider Name (Legal Business Name): MALLARY NOCOLE VENABLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 MAIN ST
PARKS LA
70582-6639
US

IV. Provider business mailing address

103 CANE HILL DR
BROUSSARD LA
70518-7459
US

V. Phone/Fax

Practice location:
  • Phone: 337-845-4663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9648
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: