Provider Demographics
NPI:1982268728
Name:MARIA WALLACE RAPID TRANSFORMATIONAL THERAPIST
Entity Type:Organization
Organization Name:MARIA WALLACE RAPID TRANSFORMATIONAL THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-288-8929
Mailing Address - Street 1:207 WAVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8091
Mailing Address - Country:US
Mailing Address - Phone:337-281-1121
Mailing Address - Fax:
Practice Address - Street 1:345 DOUCET RD STE 228
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3490
Practice Address - Country:US
Practice Address - Phone:337-281-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty