Provider Demographics
NPI:1417359431
Name:MB THERAPY
Entity Type:Organization
Organization Name:MB THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:318-278-0740
Mailing Address - Street 1:5401C JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2322
Mailing Address - Country:US
Mailing Address - Phone:318-278-0740
Mailing Address - Fax:
Practice Address - Street 1:5401C JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2322
Practice Address - Country:US
Practice Address - Phone:318-278-0740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1629065Medicaid