Provider Demographics
NPI:1154055127
Name:KASSAN, PAIGE KELLEY
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:KELLEY
Last Name:KASSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40157 LA ROCHELLE RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-5343
Mailing Address - Country:US
Mailing Address - Phone:318-787-1536
Mailing Address - Fax:
Practice Address - Street 1:821 N BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2835
Practice Address - Country:US
Practice Address - Phone:225-647-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8826235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA010874823OtherDRIVER'S LICENSE NUMBER