Provider Demographics
NPI:1164423570
Name:LAKE AREA PSYCHIATRY LLC
Entity Type:Organization
Organization Name:LAKE AREA PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTROSS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:337-478-9331
Mailing Address - Street 1:333 S RYAN ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5951
Mailing Address - Country:US
Mailing Address - Phone:337-478-9331
Mailing Address - Fax:337-478-9828
Practice Address - Street 1:333 S RYAN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5951
Practice Address - Country:US
Practice Address - Phone:337-478-9331
Practice Address - Fax:337-478-9828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CP91Medicare ID - Type Unspecified