Healthcare Provider Details

I. General information

NPI: 1669839379
Provider Name (Legal Business Name): ERIC THOMAS ROSCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 KIRKMAN ST STE A
LAKE CHARLES LA
70601-5391
US

IV. Provider business mailing address

1202 KIRKMAN ST STE A
LAKE CHARLES LA
70601-5391
US

V. Phone/Fax

Practice location:
  • Phone: 337-419-3586
  • Fax: 855-239-9737
Mailing address:
  • Phone: 337-419-3586
  • Fax: 855-239-9737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: