Provider Demographics
NPI:1932844230
Name:BRANCH, MACIE (LOTR)
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:
Last Name:BRANCH
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-5630
Mailing Address - Country:US
Mailing Address - Phone:318-525-5261
Mailing Address - Fax:
Practice Address - Street 1:1603 GOODWIN RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2907
Practice Address - Country:US
Practice Address - Phone:318-255-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324858225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist