Provider Demographics
NPI:1255565545
Name:DERANGER, MARY K (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:DERANGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:PAVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2335 CHURCH ST STE G
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-654-8208
Mailing Address - Fax:225-654-4642
Practice Address - Street 1:2335 CHURCH ST STE G
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-8208
Practice Address - Fax:225-654-4642
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200306225X00000X
LA07557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07557OtherPHYSICAL THERAPY LICENSE