Provider Demographics
NPI:1124377148
Name:LA DOUCEUR, JOHN D (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:LA DOUCEUR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 N 77TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-6866
Mailing Address - Country:US
Mailing Address - Phone:928-533-9332
Mailing Address - Fax:
Practice Address - Street 1:1475 N GRANITE REEF RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3919
Practice Address - Country:US
Practice Address - Phone:480-990-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9927225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant