Healthcare Provider Details

I. General information

NPI: 1487826210
Provider Name (Legal Business Name): COLLEEN MAIRE THOMAS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S COLLEGE RD SUITE 251
LAFAYETTE LA
70503-3212
US

IV. Provider business mailing address

909 OMEGA DR
LAFAYETTE LA
70506-2925
US

V. Phone/Fax

Practice location:
  • Phone: 337-654-9037
  • Fax: 337-993-1661
Mailing address:
  • Phone: 337-281-3608
  • Fax: 337-993-1661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2615
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: