1649529579 NPI number — TEELA LYNN FAIRCLOTH-MECHE SLP/CCC

Table of content: TEELA LYNN FAIRCLOTH-MECHE SLP/CCC (NPI 1649529579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649529579 NPI number — TEELA LYNN FAIRCLOTH-MECHE SLP/CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRCLOTH-MECHE
Provider First Name:
TEELA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP/CCC
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:
1649529579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 JOHNSON ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
JENNINGS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70546-3640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-824-4547
Provider Business Mailing Address Fax Number:
337-824-4548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 SE COURT CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWLEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-788-2300
Provider Business Practice Location Address Fax Number:
888-214-8710
Provider Enumeration Date:
09/06/2012

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:  6660 , 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)





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