Provider Demographics
NPI:1871608133
Name:CHARBONNEAU, DANA LYNN (MCD/CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LYNN
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:MCD/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 BROOKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5714
Mailing Address - Country:US
Mailing Address - Phone:318-747-9959
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5305235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist