Healthcare Provider Details

I. General information

NPI: 1356729610
Provider Name (Legal Business Name): JOHNATHON ROBERT LPC, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 RIVERSIDE DR
MONROE LA
71201-6211
US

IV. Provider business mailing address

622 RIVERSIDE DR
MONROE LA
71201-6211
US

V. Phone/Fax

Practice location:
  • Phone: 318-398-0945
  • Fax: 318-398-4314
Mailing address:
  • Phone: 318-398-0945
  • Fax: 318-398-4314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4485
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1149
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: