Provider Demographics
NPI:1174030332
Name:MATHERNE, CAROLYN CLARK (LMT LA#7483)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:CLARK
Last Name:MATHERNE
Suffix:
Gender:F
Credentials:LMT LA#7483
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:LA
Mailing Address - Zip Code:70079-2326
Mailing Address - Country:US
Mailing Address - Phone:985-974-0955
Mailing Address - Fax:
Practice Address - Street 1:1072 ORMOND BOULEVARD
Practice Address - Street 2:SUITE#A
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-3631
Practice Address - Country:US
Practice Address - Phone:985-307-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7483225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty