Provider Demographics
NPI:1528356185
Name:BONVILLAIN, EMILY CALHOUN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:CALHOUN
Last Name:BONVILLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARGARET
Other - Last Name:CALHOUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, MOT
Mailing Address - Street 1:1326 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2743
Mailing Address - Country:US
Mailing Address - Phone:225-654-8208
Mailing Address - Fax:225-654-4642
Practice Address - Street 1:1326 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2743
Practice Address - Country:US
Practice Address - Phone:225-654-8208
Practice Address - Fax:225-654-4642
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08009225100000X
LAOTT.200443225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3D085CD22Medicare PIN
LA3D086CD22Medicare PIN