Provider Demographics
NPI:1801867833
Name:PEDIATRIC THERAPY CENTER
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBEVEC
Authorized Official - Suffix:
Authorized Official - Credentials:LOTR
Authorized Official - Phone:318-448-3848
Mailing Address - Street 1:1300 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-6929
Mailing Address - Country:US
Mailing Address - Phone:318-448-3848
Mailing Address - Fax:318-448-3953
Practice Address - Street 1:1300 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-6929
Practice Address - Country:US
Practice Address - Phone:318-448-3848
Practice Address - Fax:318-448-3953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1698202Medicaid
LA1462195Medicaid