Provider Demographics
NPI:1619404779
Name:MAYON, CARLISSA
Entity Type:Individual
Prefix:
First Name:CARLISSA
Middle Name:
Last Name:MAYON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 EDITH ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5917
Mailing Address - Country:US
Mailing Address - Phone:337-942-9292
Mailing Address - Fax:337-942-9220
Practice Address - Street 1:1238 EDITH ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570
Practice Address - Country:US
Practice Address - Phone:337-942-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator