Provider Demographics
NPI:1922666551
Name:WESTSIDE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:WESTSIDE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FABRE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:225-416-0333
Mailing Address - Street 1:4171 HWY 1 S.
Mailing Address - Street 2:STE 10
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767
Mailing Address - Country:US
Mailing Address - Phone:225-416-0333
Mailing Address - Fax:225-416-0332
Practice Address - Street 1:4171 HWY 1 S.
Practice Address - Street 2:STE 10
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767
Practice Address - Country:US
Practice Address - Phone:225-416-0333
Practice Address - Fax:225-416-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2520423Medicaid