=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932623139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE WAVE PHYSICAL THERAPY AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2017
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 KINGMAN ST STE 103
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-5419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-313-6502
-----------------------------------------------------
Fax | 504-313-3910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2117 VETERANS MEMORIAL BLVD STE 313
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002-6321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-313-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CATHERINE D COURTNEY
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 504-313-6502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------