Basic Information
| Provider Information | |||||||||
| NPI: | 1982335766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUTON | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOUCET | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1326 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707912743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256548202 | ||||||||
| FaxNumber: | 2256544642 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 WALLACE BROUSSARD RD STE 300A | ||||||||
| Address2: | |||||||||
| City: | CARENCRO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705206354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373476668 | ||||||||
| FaxNumber: | 3378968288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2022 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 331797 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.