Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003338401 |
---|---|
Provider Name | Peter Brian Derouen |
First Address | Lafayette, LA 70596-1592 |
Second Address | Lafayette, LA 70508-8309 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2017 |
Last Update Date | 07/07/2017 |