Healthcare Provider Details

I. General information

NPI: 1699139329
Provider Name (Legal Business Name): THE GROVE OF LA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7384 JOHN LEBLANC BLVD
SORRENTO LA
70778-3231
US

IV. Provider business mailing address

5311 DIJON DR STE C
BATON ROUGE LA
70808-4314
US

V. Phone/Fax

Practice location:
  • Phone: 225-330-9328
  • Fax:
Mailing address:
  • Phone: 225-330-9328
  • Fax: 225-258-7098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1505
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4943
License Number StateLA

VIII. Authorized Official

Name: MS. DENISE A THIBODEAUX
Title or Position: OWNER/ CLINICAL DIRECTOR
Credential: LPC, LAC, CCS
Phone: 225-330-9328