Provider Demographics
NPI:1508491283
Name:BAHAM, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BAHAM
Suffix:
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 1:50296 RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:TICKFAW
Mailing Address - State:LA
Mailing Address - Zip Code:70466-6017
Mailing Address - Country:US
Mailing Address - Phone:985-981-9697
Mailing Address - Fax:
Practice Address - Street 1:9677 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-7205
Practice Address - Country:US
Practice Address - Phone:225-664-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3060022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer