Provider Demographics
NPI:1962967885
Name:LANDRY, LISA KATE (BS, CIT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KATE
Last Name:LANDRY
Suffix:
Gender:F
Credentials:BS, CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POYDRAS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-4740
Mailing Address - Country:US
Mailing Address - Phone:337-231-6365
Mailing Address - Fax:337-231-6371
Practice Address - Street 1:100 POYDRAS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-4740
Practice Address - Country:US
Practice Address - Phone:337-231-6365
Practice Address - Fax:337-231-6371
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4150101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1023459559Medicaid