Provider Demographics
NPI:1225603574
Name:CAMPAGNA, MARY BETH (LOT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:CAMPAGNA
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15222 OAK SHADOWS AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4389
Mailing Address - Country:US
Mailing Address - Phone:225-402-6541
Mailing Address - Fax:
Practice Address - Street 1:1050 S FOSTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7221
Practice Address - Country:US
Practice Address - Phone:225-922-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z10675225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist