Healthcare Provider Details

I. General information

NPI: 1023765542
Provider Name (Legal Business Name): MICHELLE G SYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BOWIE RD
THIBODAUX LA
70301-6703
US

IV. Provider business mailing address

PO BOX 471
THIBODAUX LA
70302-0471
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-8181
  • Fax:
Mailing address:
  • Phone: 985-447-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberAN508770
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: