Provider Demographics
NPI:1821216102
Name:GAUTREAUX, BRANDI (OT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:GAUTREAUX
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 BAYOU OAK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2629
Mailing Address - Country:US
Mailing Address - Phone:337-274-6744
Mailing Address - Fax:
Practice Address - Street 1:817 BAYOU OAK LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2629
Practice Address - Country:US
Practice Address - Phone:337-274-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068675Medicaid