Provider Demographics
NPI:1508698051
Name:DESLATTES, THOMAS W
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:DESLATTES
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8105 COLQUITT RD
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-9099
Mailing Address - Country:US
Mailing Address - Phone:318-560-0299
Mailing Address - Fax:
Practice Address - Street 1:3821 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1033
Practice Address - Country:US
Practice Address - Phone:318-946-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator