Provider Demographics
NPI:1679010136
Name:GUILBEAUX, MAYA
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:GUILBEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 JOHNSTON ST
Mailing Address - Street 2:STE. B
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2756
Mailing Address - Country:US
Mailing Address - Phone:337-233-7250
Mailing Address - Fax:337-233-7104
Practice Address - Street 1:2448 JOHNSTON ST
Practice Address - Street 2:STE. B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2756
Practice Address - Country:US
Practice Address - Phone:337-233-7250
Practice Address - Fax:337-233-7104
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600720410Medicaid