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General NPI Number Information
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NPI Number | 1720990047
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Entity Type | Organization
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Legal Business Name | BAYOU ROOTS INTEGRATED CARE
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Dates
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Enumeration Date | 09/21/2026
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Last Update Date | 09/21/2026
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Provider Practice Location Address
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Address Line | 3714 LOUISIANA AVE
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City | LAKE CHARLES
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State | LA
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Zip | 70607-3044
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Country | US
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Telephone | 337-391-9976
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 143
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City | LAKE CHARLES
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State | LA
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Zip | 70602-0143
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ASHLEY ANTIONETTE MONTGOMERY
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Credential | PMHNP-BC
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Telephone | 337-391-9976
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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