Basic Information
| Provider Information | |||||||||
| NPI: | 1114962917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHARDE | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | COOK | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 WHISPERWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704581136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856412866 | ||||||||
| FaxNumber: | 9857815395 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 WHISPERWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704581136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856412866 | ||||||||
| FaxNumber: | 9857815395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 06416 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | H2868 | 01 | LA | BLUECROSS BLUESHIELD | OTHER |