Provider Demographics
NPI:1568072932
Name:PETTITT, ANGELA MICHELLE (MS, L-SLP, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MICHELLE
Last Name:PETTITT
Suffix:
Gender:F
Credentials:MS, L-SLP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754-1130
Mailing Address - Country:US
Mailing Address - Phone:225-665-0446
Mailing Address - Fax:
Practice Address - Street 1:23946 SOUTHPARK LN
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-6898
Practice Address - Country:US
Practice Address - Phone:225-276-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2644441Medicaid