Provider Demographics
NPI:1417735242
Name:DUPART, ANGELAIN JOSEPH IV
Entity Type:Individual
Prefix:
First Name:ANGELAIN
Middle Name:JOSEPH
Last Name:DUPART
Suffix:IV
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 1:1215 INDEPENDENCE BLVD BLDG 6
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7390
Mailing Address - Country:US
Mailing Address - Phone:225-286-1547
Mailing Address - Fax:
Practice Address - Street 1:1215 INDEPENDENCE BLVD BLDG 6
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7390
Practice Address - Country:US
Practice Address - Phone:225-286-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012689446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician