Provider Demographics
NPI:1629332721
Name:PEDIATRIC THERAPY OF LOUISIANA
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:337-540-1861
Mailing Address - Street 1:4106 MAID STONE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4030
Mailing Address - Country:US
Mailing Address - Phone:337-540-1861
Mailing Address - Fax:
Practice Address - Street 1:4106 MAID STONE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4030
Practice Address - Country:US
Practice Address - Phone:337-540-1861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA235Z00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty