Provider Demographics
NPI:1861452187
Name:GUILLORY, JOHN TOBEN (OT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TOBEN
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5508
Mailing Address - Country:US
Mailing Address - Phone:318-323-1110
Mailing Address - Fax:318-323-1510
Practice Address - Street 1:1014 N 4TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5508
Practice Address - Country:US
Practice Address - Phone:318-323-1110
Practice Address - Fax:318-323-1510
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ71114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5X971Medicare ID - Type UnspecifiedMEDICARE IDENTIFIER