Provider Demographics
NPI:1790822195
Name:JUNEAU, WENDELL (PT)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:
Last Name:JUNEAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 VEROT SCHOOL RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5094
Mailing Address - Country:US
Mailing Address - Phone:337-406-0808
Mailing Address - Fax:337-406-0848
Practice Address - Street 1:626 VEROT SCHOOL RD
Practice Address - Street 2:SUITE E
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5094
Practice Address - Country:US
Practice Address - Phone:337-406-0808
Practice Address - Fax:337-406-0848
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B711CD63Medicare ID - Type Unspecified1