Healthcare Provider Details

I. General information

NPI: 1598050262
Provider Name (Legal Business Name): AMY NICOLE DYSART LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 LOUISA AVE
RAYNE LA
70578-7230
US

IV. Provider business mailing address

908 LOUISA AVE
RAYNE LA
70578-7230
US

V. Phone/Fax

Practice location:
  • Phone: 225-270-0100
  • Fax:
Mailing address:
  • Phone: 225-270-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: