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NPI Code Detail

MEDICARE: MARTHA LYNN FONTENOT LAC

MEDICARE: MARTHA LYNN FONTENOT 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
1101YA0400XAddiction (Substance Use Disorder) Counselor808LA

General Provider Information

NPI Number : 1639329022
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARTHA LYNN FONTENOT LAC
Provider Business Mailing Address
First Line : 913 ARDMORE ST
Second Line :
City : LAKE CHARLES
State : LA
Zip : 70605-5476
Country : US
Telephone Number : 337-302-3157
Fax Number :
Provider Business Practice Location Address
First Line : 614 ESPLANADE ST
Second Line :
City : LAKE CHARLES
State : LA
Zip : 70607-6308
Country : US
Telephone Number : 337-478-1411
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/23/2008
Last Update Date : 07/29/2011

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Directions to “ MARTHA LYNN FONTENOT LAC” Practice Location

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