=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720319775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSEPHANIE SILVERTHORN PHD LICENSED CLINICAL PSYCHOLOGIST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2010
-----------------------------------------------------
Last Update Date | 01/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 887 HAILEY AVE
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-4437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-661-8400
-----------------------------------------------------
Fax | 985-643-7454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 887 HAILEY AVE
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-4437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-661-8400
-----------------------------------------------------
Fax | 985-643-7454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. PERSEPHANIE SILVERTHORN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 985-661-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 868
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------