Provider Demographics
NPI:1558621482
Name:GUIDRY, DEREK (DP, DPT)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:GUIDRY
Suffix:
Gender:M
Credentials:DP, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 OAK CREEK RD APT 240
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-5871
Mailing Address - Country:US
Mailing Address - Phone:985-641-2866
Mailing Address - Fax:
Practice Address - Street 1:720 BROWNSWITCH RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1262
Practice Address - Country:US
Practice Address - Phone:985-641-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA08302OtherPHYSICAL THERAPIST LICENSE