Healthcare Provider Details

I. General information

NPI: 1215665682
Provider Name (Legal Business Name): MARY C GENO MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14417 HIGHWAY 442 W
TICKFAW LA
70466-3022
US

IV. Provider business mailing address

14417 HIGHWAY 442 W
TICKFAW LA
70466-3022
US

V. Phone/Fax

Practice location:
  • Phone: 985-345-2166
  • Fax:
Mailing address:
  • Phone: 985-345-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1981
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: