Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 4770 | LA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 4770 | LA |
Y | 103TF0000X | Family Psychologist | 4770 | LA |
NPI | 1235534512 |
---|---|
Provider Name | Beau S Dantin |
First Address | Baton Rouge, LA 70809-1481 |
Second Address | Baton Rouge, LA 70809-1481 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2014 |
Last Update Date | 28/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000000 | (05) | LA |