Provider Demographics
NPI:1275716524
Name:PEDIATRIC THERAPY AND LEARNING CENTER LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY AND LEARNING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGOULLON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCCD-SLP
Authorized Official - Phone:337-504-4244
Mailing Address - Street 1:108 ENERGY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3818
Mailing Address - Country:US
Mailing Address - Phone:337-504-4244
Mailing Address - Fax:337-706-7612
Practice Address - Street 1:108 ENERGY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3818
Practice Address - Country:US
Practice Address - Phone:337-504-4244
Practice Address - Fax:337-706-7612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
LA4981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty