Healthcare Provider Details

I. General information

NPI: 1871104208
Provider Name (Legal Business Name): THE THERAPY GARDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 07/09/2022
Certification Date: 07/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COULEE SHORE DR
LAFAYETTE LA
70503-3021
US

IV. Provider business mailing address

100 COULEE SHORE DR
LAFAYETTE LA
70503-3021
US

V. Phone/Fax

Practice location:
  • Phone: 337-254-0362
  • Fax:
Mailing address:
  • Phone: 318-787-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN DIETZWAY
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: LCSW
Phone: 337-254-0362