Provider Demographics
NPI:1194782276
Name:LILES, ANJELIQUE VIA (MPT)
Entity type:Individual
Prefix:
First Name:ANJELIQUE
Middle Name:VIA
Last Name:LILES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 FERRAND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3212
Mailing Address - Country:US
Mailing Address - Phone:318-387-4973
Mailing Address - Fax:318-322-4093
Practice Address - Street 1:2601 FERRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3212
Practice Address - Country:US
Practice Address - Phone:318-387-4973
Practice Address - Fax:318-322-4093
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist