Healthcare Provider Details

I. General information

NPI: 1497335160
Provider Name (Legal Business Name): THORN T PHILLIPS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23363 S ROBIN RD # QUADB
MANDEVILLE LA
70448-7381
US

IV. Provider business mailing address

23363 S ROBIN RD # QUADB
MANDEVILLE LA
70448-7381
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-4118
  • Fax: 985-690-6662
Mailing address:
  • Phone: 985-624-4118
  • Fax: 985-624-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLPC7769
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC7769
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC7769
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberLPC7769
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberPLC7769
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: