Healthcare Provider Details

I. General information

NPI: 1477260578
Provider Name (Legal Business Name): CHRISTY MAMOU PSY,D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20108 BUR OAK DR
ZACHARY LA
70791-5352
US

IV. Provider business mailing address

PO BOX 1754
ZACHARY LA
70791-1754
US

V. Phone/Fax

Practice location:
  • Phone: 225-286-9355
  • Fax:
Mailing address:
  • Phone: 225-286-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCM-100691
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number250896
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: