Provider Demographics
NPI:1558697995
Name:RANDALL, EMILY METTLACH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:METTLACH
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 GAUSE BLVD E STE 6
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4243
Mailing Address - Country:US
Mailing Address - Phone:985-646-2531
Mailing Address - Fax:985-649-1391
Practice Address - Street 1:2132 GAUSE BLVD E STE 6
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4243
Practice Address - Country:US
Practice Address - Phone:985-646-2531
Practice Address - Fax:985-649-1391
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4621225100000X
LA08268R2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist