Provider Demographics
NPI:1134456916
Name:UPSHAW, ADELE (PT)
Entity Type:Individual
Prefix:
First Name:ADELE
Middle Name:
Last Name:UPSHAW
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 1:191 SANCTUARY RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1716
Mailing Address - Country:US
Mailing Address - Phone:318-255-9601
Mailing Address - Fax:
Practice Address - Street 1:1923 FARMERVILLE HWY
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3007
Practice Address - Country:US
Practice Address - Phone:318-255-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02155F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169234Medicaid
LA1169234Medicaid