MEDICARE: GERIATRIC PSYCHOLOGICAL SERVICES OF LOUISIANA APC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1326325127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC PSYCHOLOGICAL SERVICES OF LOUISIANA APC

Provider Business Mailing Address
First Line	:	100 ASMA BLVD
Second Line	:	SUITE 237E
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3858
Country	:	US
Telephone Number	:	337-267-1444
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 ASMA BLVD
Second Line	:	SUITE 237E
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3858
Country	:	US
Telephone Number	:	337-267-1444
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. EDMOND X BERGERON
Credential	:	PH.D., M.P
Telephone Number	:	337-267-1444

Provider Enumeration Date	:	11/08/2011
Last Update Date	:	02/27/2013

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