Healthcare Provider Details

I. General information

NPI: 1376062828
Provider Name (Legal Business Name): FERMINE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 HOMER RD
MINDEN LA
71055-2833
US

IV. Provider business mailing address

2525 YOUREE DR STE 110
SHREVEPORT LA
71104-3600
US

V. Phone/Fax

Practice location:
  • Phone: 318-639-9562
  • Fax:
Mailing address:
  • Phone: 318-742-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: