MEDICARE: MR. BEAU MICHAELS LAVIOLETTE I LCSW, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1401	LA
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1114470762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BEAU MICHAELS LAVIOLETTE I LCSW, LAC

Provider Business Mailing Address
First Line	:	13131 WOODRIDGE AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-5209
Country	:	US
Telephone Number	:	504-261-8654
Fax Number	:

Provider Business Practice Location Address
First Line	:	11843 BRICKSOME AVE STE A
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-5310
Country	:	US
Telephone Number	:	504-261-8654
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	07/24/2019

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