Basic Information
| Provider Information | |||||||||
| NPI: | 1013474196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUE | ||||||||
| FirstName: | CHRISTI | ||||||||
| MiddleName: | THIBODEAUX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 W TUNNEL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703605591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857465681 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 427WEST TUNNEL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857465681 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1255681128 | 05 | LA | MEDICAID |