Provider Demographics
NPI:1447742473
Name:POULAN, GLENDA GRAVOUILLA (LRST)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:GRAVOUILLA
Last Name:POULAN
Suffix:
Gender:F
Credentials:LRST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 GUILBEAU RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6914
Mailing Address - Country:US
Mailing Address - Phone:337-989-0120
Mailing Address - Fax:214-602-4526
Practice Address - Street 1:330 GUILBEAU RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:372-475-2473
Practice Address - Fax:214-602-4526
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No172A00000XOther Service ProvidersDriver