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General NPI Number Information
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NPI Number | 1154557726
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Entity Type | Organization
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Legal Business Name | LAKE AREA NEUROPSYCHOLOGY ASSOCIATES INC
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Dates
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Enumeration Date | 06/09/2009
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Last Update Date | 06/09/2009
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Provider Practice Location Address
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Address Line | 803 W BAYOU PINES DR STE F
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7096
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Country | US
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Telephone | 337-436-1631
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Fax |
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Provider Business Mailing Address
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Address Line | 803 W BAYOU PINES DR STE F
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7096
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Country | US
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Telephone | 337-436-1631
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | CHARLES M. ROBERTSON
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Credential | PSY.D.
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Telephone | 337-436-1631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 604
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License Number State | LA
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