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General NPI Number Information
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NPI Number | 1639567290
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Entity Type | Organization
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Legal Business Name | THE EQUESTRIAN THERAPY CENTER OF SLIDELL
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Dates
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Enumeration Date | 01/06/2015
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Last Update Date | 01/06/2015
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Provider Practice Location Address
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Address Line | 32597 C C RD
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City | SLIDELL
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State | LA
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Zip | 70460-3269
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Country | US
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Telephone | 985-641-4934
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Fax | 985-649-0982
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Provider Business Mailing Address
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Address Line | 32597 C C RD
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City | SLIDELL
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State | LA
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Zip | 70460-3269
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Country | US
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Telephone | 985-641-4934
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Fax | 985-649-0982
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Authorized Official
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Title or Position | OWNER
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Name | DR. BEVERLY STUBBLEFIELD
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Credential | PH.D.
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Telephone | 985-641-4934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1297
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License Number State | LA
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