Provider Demographics
NPI:1396499364
Name:MATT, DAMIAN LARK (PLPC)
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:LARK
Last Name:MATT
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6622
Mailing Address - Country:US
Mailing Address - Phone:337-210-5844
Mailing Address - Fax:225-214-1655
Practice Address - Street 1:4640 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6622
Practice Address - Country:US
Practice Address - Phone:337-210-5844
Practice Address - Fax:225-214-1655
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8712101Y00000X, 101YP2500X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8712OtherLICENSE