Provider Demographics
NPI:1114962917
Name:DEHARDE, ANGIE COOK (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:COOK
Last Name:DEHARDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 WHISPERWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-1136
Mailing Address - Country:US
Mailing Address - Phone:985-641-2866
Mailing Address - Fax:985-781-5395
Practice Address - Street 1:85 WHISPERWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1136
Practice Address - Country:US
Practice Address - Phone:985-641-2866
Practice Address - Fax:985-781-5395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH2868OtherBLUECROSS BLUESHIELD