Provider Demographics
NPI:1417313420
Name:FERROUILLET, IVAN MYLES
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:MYLES
Last Name:FERROUILLET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S SOLOMON ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5928
Mailing Address - Country:US
Mailing Address - Phone:504-676-0748
Mailing Address - Fax:
Practice Address - Street 1:127 S SOLOMON ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5928
Practice Address - Country:US
Practice Address - Phone:504-676-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA000000000000000000101Y00000X
LA15066171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor