Provider Demographics
NPI:1285690834
Name:MAASSEN, MIRJAM NICOLE (PT)
Entity type:Individual
Prefix:MS
First Name:MIRJAM
Middle Name:NICOLE
Last Name:MAASSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5627 BANKERS AVE.
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-927-3000
Mailing Address - Fax:225-927-4183
Practice Address - Street 1:5627 BANKERS AVE.
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-927-3000
Practice Address - Fax:225-927-4183
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01436F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C452Medicare ID - Type Unspecified