Individual
LADETRICK PROVO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
5476 SUMMER DR, BATON ROUGE, LA 70812-3046
(225) 333-7899
Mailing address
5476 SUMMER DR, BATON ROUGE, LA 70812-3046
(225) 333-7899
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000000
—
LA
Enumeration date
03/24/2017
Last updated
03/24/2017
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