Healthcare Provider Details

I. General information

NPI: 1902144645
Provider Name (Legal Business Name): ANDREW JUSTIN THRASHER III PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5521 AIRLINE DR STE B
BOSSIER CITY LA
71111-6801
US

IV. Provider business mailing address

5113 WATERS EDGE DR
BENTON LA
71006-2501
US

V. Phone/Fax

Practice location:
  • Phone: 318-507-0621
  • Fax: 225-208-1056
Mailing address:
  • Phone: 337-244-1641
  • Fax: 225-208-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1412
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: