Basic Information
| Provider Information | |||||||||
| NPI: | 1700388287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEBOEUF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | STEVENS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1418 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854494055 | ||||||||
| FaxNumber: | 9854494178 | ||||||||
| Practice Location | |||||||||
| Address1: | 1418 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854494055 | ||||||||
| FaxNumber: | 9854494178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.