Healthcare Provider Details

I. General information

NPI: 1639200827
Provider Name (Legal Business Name): MARJORIE BLOCK MATHERNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N ACADIA RD SUITE 201
THIBODAUX LA
70301-4847
US

IV. Provider business mailing address

604 NORTH ACADIA ROAD, SUITE 201
THIBODAUX LA
70301-4847
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-9304
  • Fax: 985-493-9305
Mailing address:
  • Phone: 985-493-9304
  • Fax: 985-493-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4920
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: