Provider Demographics
NPI:1588654347
Name:CHELETTE, BRYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:CHELETTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 CHURCH ST
Mailing Address - Street 2:STE G
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-654-8208
Mailing Address - Fax:225-654-4642
Practice Address - Street 1:2335 CHURCH ST
Practice Address - Street 2:STE G
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-8208
Practice Address - Fax:225-654-4642
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H331C943OtherMEDICARE
LA1022519Medicaid