Healthcare Provider Details

I. General information

NPI: 1972852143
Provider Name (Legal Business Name): LAURA D THIESEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA V THIESEN LCSW

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 E ASCENSION COMPLEX BLVD
GONZALES LA
70737-4265
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-450-1016
  • Fax: 225-450-1150
Mailing address:
  • Phone: 225-450-1016
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1187
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17690
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: