Provider Demographics
NPI:1912291857
Name:DAUTERIVE, CRAIG D (DPT)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:D
Last Name:DAUTERIVE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9629 MARSHA DR
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-2009
Mailing Address - Country:US
Mailing Address - Phone:504-390-2076
Mailing Address - Fax:
Practice Address - Street 1:6824 VETERANS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003
Practice Address - Country:US
Practice Address - Phone:504-301-0061
Practice Address - Fax:504-301-0062
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT08071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H165CK91Medicare Oscar/Certification