Healthcare Provider Details

I. General information

NPI: 1083148506
Provider Name (Legal Business Name): LAOTIS DEE DENNIS MHP, M.S.C.J
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAOTIS NICKELSON MPH, M.S.C.J

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 NW 2ND ST
RESERVE LA
70084
US

IV. Provider business mailing address

3205 HWY 51 SUITE C
LAPLACE LA
70068
US

V. Phone/Fax

Practice location:
  • Phone: 985-233-1689
  • Fax:
Mailing address:
  • Phone: 985-651-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number009462156
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: