Healthcare Provider Details

I. General information

NPI: 1316408693
Provider Name (Legal Business Name): THERAPEUTIC TRANSFORMATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 UNIVERSITY AVE # 105
MONROE LA
71209-9000
US

IV. Provider business mailing address

700 UNIVERSITY AVE # 105
MONROE LA
71209-9000
US

V. Phone/Fax

Practice location:
  • Phone: 318-237-9948
  • Fax: 318-325-8749
Mailing address:
  • Phone: 318-237-9948
  • Fax: 318-325-8749

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: ALETHA A NELSON
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC-S
Phone: 318-237-9948