Provider Demographics
NPI:1619076569
Name:AUSTIN, TERTIUS L III (LOTR)
Entity Type:Individual
Prefix:MR
First Name:TERTIUS
Middle Name:L
Last Name:AUSTIN
Suffix:III
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 W DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2001
Mailing Address - Country:US
Mailing Address - Phone:318-372-1115
Mailing Address - Fax:
Practice Address - Street 1:2110 JUSTICE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3618
Practice Address - Country:US
Practice Address - Phone:318-322-8811
Practice Address - Fax:318-322-8368
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4H006Medicare UPIN
48006 CG53Medicare ID - Type Unspecified