Healthcare Provider Details

I. General information

NPI: 1992206783
Provider Name (Legal Business Name): MONIQUE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 TIGER DR
THIBODAUX LA
70301-4337
US

IV. Provider business mailing address

1418 TIGER DR
THIBODAUX LA
70301-4337
US

V. Phone/Fax

Practice location:
  • Phone: 985-449-4055
  • Fax:
Mailing address:
  • Phone: 985-449-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC9039
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: