Provider Demographics
NPI:1063613693
Name:FELICE, AMY ROSE (RAC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ROSE
Last Name:FELICE
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W KENT DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5028
Mailing Address - Country:US
Mailing Address - Phone:337-274-1511
Mailing Address - Fax:
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-8022
Practice Address - Fax:337-475-8054
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2415 CIT101YA0400X
LA1359 RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CV41Medicare ID - Type Unspecified