Provider Demographics
NPI:1790780120
Name:THERAPEUTIC BY DESIGN FITNESS AND WELLNESS, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC BY DESIGN FITNESS AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FABRE FAIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PHD, CSCS
Authorized Official - Phone:985-778-2282
Mailing Address - Street 1:1901 HIGHWAY 190 STE 26
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3495
Mailing Address - Country:US
Mailing Address - Phone:985-778-2282
Mailing Address - Fax:866-767-8329
Practice Address - Street 1:1901 HIGHWAY 190 STE 26
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3495
Practice Address - Country:US
Practice Address - Phone:985-778-2282
Practice Address - Fax:866-767-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1715026Medicaid
LA1715026Medicaid