Provider Demographics
NPI:1235262775
Name:BERTHIAUME, WEDNESDAY (OT)
Entity Type:Individual
Prefix:
First Name:WEDNESDAY
Middle Name:
Last Name:BERTHIAUME
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 LAKE MECHANT CT
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-8328
Mailing Address - Country:US
Mailing Address - Phone:985-232-5505
Mailing Address - Fax:985-851-5828
Practice Address - Street 1:269 LAKE MECHANT CT
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-8328
Practice Address - Country:US
Practice Address - Phone:985-232-5505
Practice Address - Fax:985-851-5828
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12478225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473901Medicaid