Healthcare Provider Details

I. General information

NPI: 1518337427
Provider Name (Legal Business Name): MARCELLA THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 JOHNSTON ST
LAFAYETTE LA
70503-2756
US

IV. Provider business mailing address

2448 JOHNSTON ST
LAFAYETTE LA
70503-2756
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-7250
  • Fax:
Mailing address:
  • Phone: 337-233-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: