Provider Demographics
NPI:1699920181
Name:CLEMENT DERISE, JOY CHARMAINE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:JOY
Middle Name:CHARMAINE
Last Name:CLEMENT DERISE
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 W SALE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2579
Mailing Address - Country:US
Mailing Address - Phone:337-480-1100
Mailing Address - Fax:337-480-1174
Practice Address - Street 1:1737 W SALE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2579
Practice Address - Country:US
Practice Address - Phone:337-480-1100
Practice Address - Fax:337-480-1174
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA0048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist