Provider Demographics
NPI:1447425335
Name:MATHERNE, SHANA
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:MATHERNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 159
Mailing Address - Street 2:
Mailing Address - City:LAROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70373
Mailing Address - Country:US
Mailing Address - Phone:985-798-7557
Mailing Address - Fax:
Practice Address - Street 1:13343 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAROSE
Practice Address - State:LA
Practice Address - Zip Code:70373
Practice Address - Country:US
Practice Address - Phone:985-798-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant