MEDICARE: SELF-ISH, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	251S00000X	Community/Behavioral Health Agency
3	101Y00000X	Counselor

General Provider Information

NPI Number	:	1730843012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF-ISH, LLC

Provider Business Mailing Address
First Line	:	4310 RYAN ST STE 134
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4514
Country	:	US
Telephone Number	:	337-873-1203
Fax Number	:

Provider Business Practice Location Address
First Line	:	4310 RYAN ST STE 134
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4514
Country	:	US
Telephone Number	:	337-873-1203
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROYCE CHARLES
Credential	:
Telephone Number	:	337-873-1203

Provider Enumeration Date	:	10/24/2021
Last Update Date	:	10/28/2021

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Directions to “SELF-ISH, LLC ” Practice Location

Language	Start Address	Practice Location

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