Healthcare Provider Details

I. General information

NPI: 1740568872
Provider Name (Legal Business Name): JAMES W QUILLIN, PHD, APPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 CALAIS CIR
ALEXANDRIA LA
71303-2307
US

IV. Provider business mailing address

1016 CALAIS CIR
ALEXANDRIA LA
71303-2307
US

V. Phone/Fax

Practice location:
  • Phone: 318-442-7355
  • Fax: 318-442-4407
Mailing address:
  • Phone: 318-442-7355
  • Fax: 318-442-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0318MP
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0318MP
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2498
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1288
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1288
License Number StateLA
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0318 MP
License Number StateLA

VIII. Authorized Official

Name: DR. JAMES WESLEY QUILLIN
Title or Position: PRESIDENT
Credential: PHD, MP
Phone: 318-442-7355