Provider Demographics
NPI:1518306141
Name:GOBERT, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:GOBERT
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 1:1506 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70615-4977
Mailing Address - Country:US
Mailing Address - Phone:337-309-5692
Mailing Address - Fax:337-855-1829
Practice Address - Street 1:1506 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70615-4977
Practice Address - Country:US
Practice Address - Phone:337-309-5692
Practice Address - Fax:337-855-1829
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1029530Medicaid