Provider Demographics
NPI:1225249469
Name:LAROSE, NICOLE GRAUGNARD
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRAUGNARD
Last Name:LAROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:EDGARD
Mailing Address - State:LA
Mailing Address - Zip Code:70049-0005
Mailing Address - Country:US
Mailing Address - Phone:985-497-3224
Mailing Address - Fax:
Practice Address - Street 1:1808 BAYOU RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-6034
Practice Address - Country:US
Practice Address - Phone:985-497-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3254235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1409405Medicaid