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General NPI Number Information
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NPI Number | 1629332721
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Entity Type | Organization
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Legal Business Name | PEDIATRIC THERAPY OF LOUISIANA
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Dates
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Enumeration Date | 07/03/2012
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Last Update Date | 07/03/2012
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Provider Practice Location Address
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Address Line | 4106 MAID STONE DR
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4030
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Country | US
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Telephone | 337-540-1861
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Fax |
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Provider Business Mailing Address
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Address Line | 4106 MAID STONE DR
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4030
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Country | US
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Telephone | 337-540-1861
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. ALISA TRAHAN
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Credential | M.A., CCC-SLP
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Telephone | 337-540-1861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State | LA
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