Provider Demographics
NPI:1164591038
Name:THE SPEECH PATHOLOGY CENTER OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:THE SPEECH PATHOLOGY CENTER OF LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONDRA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:FAZELY
Authorized Official - Suffix:
Authorized Official - Credentials:CCC
Authorized Official - Phone:225-923-1140
Mailing Address - Street 1:8676 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7914
Mailing Address - Country:US
Mailing Address - Phone:225-923-1140
Mailing Address - Fax:225-923-1326
Practice Address - Street 1:8676 GOODWOOD BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7914
Practice Address - Country:US
Practice Address - Phone:225-923-1140
Practice Address - Fax:225-923-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty