Provider Demographics
NPI:1497371074
Name:FORTENBERRY, CECILIA MARIE
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MARIE
Last Name:FORTENBERRY
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 1:108 EASY ST
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225-8555
Mailing Address - Country:US
Mailing Address - Phone:318-450-9479
Mailing Address - Fax:
Practice Address - Street 1:810 N 29TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3704
Practice Address - Country:US
Practice Address - Phone:318-600-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8649235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist