Provider Demographics
NPI:1578924825
Name:JOSEPH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:BAKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1530 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-8811
Mailing Address - Country:US
Mailing Address - Phone:985-259-0601
Mailing Address - Fax:
Practice Address - Street 1:8550 UNITED PLAZA BLVD.
Practice Address - Street 2:STE 702-N
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-0200
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist