Basic Information
| Provider Information | |||||||||
| NPI: | 1013552801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONNIER | ||||||||
| FirstName: | MYA | ||||||||
| MiddleName: | TENAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2829 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374777091 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ENERGY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374374014 | ||||||||
| FaxNumber: | 3374378283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2019 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
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 | 1551228 | 05 | LA | MEDICAID |