Provider Demographics
NPI:1396913224
Name:COLLETTE, BRYAN JOSEPH
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOSEPH
Last Name:COLLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 REES ST
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-4310
Mailing Address - Country:US
Mailing Address - Phone:337-332-2730
Mailing Address - Fax:337-332-2711
Practice Address - Street 1:1510 REES ST
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4310
Practice Address - Country:US
Practice Address - Phone:337-332-2730
Practice Address - Fax:337-332-2711
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34289171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1353345OtherTYPE 15 MEDICAID
LA1001848Medicaid