Provider Demographics
NPI:1659915304
Name:RIDEAUX, MIKAYLIA DANIELLE
Entity Type:Individual
Prefix:
First Name:MIKAYLIA
Middle Name:DANIELLE
Last Name:RIDEAUX
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 1:1732 S WASHINGTON ST APT 39
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-3943
Mailing Address - Country:US
Mailing Address - Phone:337-692-6976
Mailing Address - Fax:
Practice Address - Street 1:209 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6256
Practice Address - Country:US
Practice Address - Phone:337-942-6400
Practice Address - Fax:337-948-7400
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator