Provider Demographics
NPI:1083647127
Name:CHERALLA, MARK T (MPT, LOTR)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:CHERALLA
Suffix:
Gender:M
Credentials:MPT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7936 OFFICE PARK BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809
Mailing Address - Country:US
Mailing Address - Phone:225-201-0002
Mailing Address - Fax:225-201-0040
Practice Address - Street 1:7936 OFFICE PARK BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-201-0002
Practice Address - Fax:225-201-0040
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06302225100000X
LAOTTZ12348225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4C031C802Medicare ID - Type Unspecified