1588854079 NPI number — MS. THELMA DIANE BROADHURST MA, CCC-SLP

Table of content: MS. THELMA DIANE BROADHURST MA, CCC-SLP (NPI 1588854079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588854079 NPI number — MS. THELMA DIANE BROADHURST MA, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADHURST
Provider First Name:
THELMA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588854079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 MARIETTA ST.
Provider Second Line Business Mailing Address:
P. O. BOX 86
Provider Business Mailing Address City Name:
OAK GROVE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71263-0086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-428-3659
Provider Business Mailing Address Fax Number:
318-428-3659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 MARIETTA ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK GROVE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71263-0086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-428-3659
Provider Business Practice Location Address Fax Number:
318-428-3659
Provider Enumeration Date:
07/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  4265 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1302082 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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