Provider Demographics
NPI:1376650846
Name:REMILLARD, MICHAEL WALTER (LAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WALTER
Last Name:REMILLARD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6636
Mailing Address - Country:US
Mailing Address - Phone:318-362-4160
Mailing Address - Fax:318-362-4238
Practice Address - Street 1:2913 DESIARD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7207
Practice Address - Country:US
Practice Address - Phone:318-362-4160
Practice Address - Fax:318-362-4238
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC #853101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)