MEDICARE: TIFFANY SIMONEAUX GUIDRY LOTR

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	225XP0200X	Pediatric Occupational Therapist	Z11845	LA

General Provider Information

NPI Number	:	1972725661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY SIMONEAUX GUIDRY LOTR

Provider Business Mailing Address
First Line	:	37427 MILL PARK AVE
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6198
Country	:	US
Telephone Number	:	225-938-2602
Fax Number	:

Provider Business Practice Location Address
First Line	:	37427 MILL PARK AVE
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-6198
Country	:	US
Telephone Number	:	225-938-2602
Fax Number	:

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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