Provider Demographics
NPI:1407082233
Name:ALFONSO, AMY R (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:R
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 PLANTATION BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-7500
Mailing Address - Country:US
Mailing Address - Phone:985-624-4934
Mailing Address - Fax:
Practice Address - Street 1:665 PLANTATION BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-7500
Practice Address - Country:US
Practice Address - Phone:985-624-4934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT Z12081225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist