Healthcare Provider Details

I. General information

NPI: 1114370582
Provider Name (Legal Business Name): CHERRY WILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 LAURA DR SUITE D
THIBODAUX LA
70301-2988
US

IV. Provider business mailing address

142 LAURA DR SUITE D
THIBODAUX LA
70301-2988
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-4114
  • Fax: 985-446-4112
Mailing address:
  • Phone: 985-446-4114
  • Fax: 985-446-4112

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:
Title or Position:
Credential:
Phone: