Provider Demographics
NPI:1326609462
Name:TRAHAN, SPARKY JOEL (PSS)
Entity Type:Individual
Prefix:
First Name:SPARKY
Middle Name:JOEL
Last Name:TRAHAN
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124A HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4322
Mailing Address - Country:US
Mailing Address - Phone:985-857-3615
Mailing Address - Fax:
Practice Address - Street 1:5599 HIGHWAY 311
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2866
Practice Address - Country:US
Practice Address - Phone:985-857-3615
Practice Address - Fax:985-876-8824
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA461634964OtherPEER SUPPORT SPECIALLIST