Provider Demographics
NPI:1285841551
Name:DYSART GAGNARD, CORI D (MED)
Entity Type:Individual
Prefix:MRS
First Name:CORI
Middle Name:D
Last Name:DYSART GAGNARD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SWIFT FOX RUN
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3113
Mailing Address - Country:US
Mailing Address - Phone:504-236-6810
Mailing Address - Fax:985-792-5305
Practice Address - Street 1:24265 CANE BYU
Practice Address - Street 2:
Practice Address - City:LACOMBE
Practice Address - State:LA
Practice Address - Zip Code:70445-6125
Practice Address - Country:US
Practice Address - Phone:985-869-4183
Practice Address - Fax:985-898-2940
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55822355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1527807Medicaid