Provider Demographics
NPI:1134284557
Name:GREMILLION, MARK P (OT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:GREMILLION
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 RICHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6606
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:2002 JOHNSON ST STE 100
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3646
Practice Address - Country:US
Practice Address - Phone:337-824-4547
Practice Address - Fax:337-824-4548
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10533225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5X881Medicare ID - Type UnspecifiedOT MEDICARE #