Provider Demographics
NPI:1124430103
Name:PERRY, WANDA KAREN (CR, LMT, CMM)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:KAREN
Last Name:PERRY
Suffix:
Gender:F
Credentials:CR, LMT, CMM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:LA
Mailing Address - Zip Code:70441-0663
Mailing Address - Country:US
Mailing Address - Phone:985-507-7617
Mailing Address - Fax:
Practice Address - Street 1:12357 HAYNES ST.
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3717
Practice Address - Country:US
Practice Address - Phone:985-507-7617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173C00000X
LA3985225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist