Provider Demographics
NPI:1538416524
Name:PERSICK, MANDY DALTON (OT)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:DALTON
Last Name:PERSICK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1630 RUE DU BELIER APT 409
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6550
Mailing Address - Country:US
Mailing Address - Phone:337-824-5488
Mailing Address - Fax:337-824-5494
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE I
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4100
Practice Address - Country:US
Practice Address - Phone:337-824-5488
Practice Address - Fax:337-824-5494
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200553225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist