Provider Demographics
NPI:1083829766
Name:WILTZ, STELLA (OWNER)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:WILTZ
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-6039
Mailing Address - Country:US
Mailing Address - Phone:337-332-1810
Mailing Address - Fax:337-332-3300
Practice Address - Street 1:402 RICHARD STREET
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-7051
Practice Address - Country:US
Practice Address - Phone:337-278-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 3747P1801X
LA112263747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA84-368-5768Medicaid
LA1721999Medicaid