Provider Demographics
NPI:1902274467
Name:PSYCHOTHERAPY CLINIC LLC
Entity Type:Organization
Organization Name:PSYCHOTHERAPY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:THRASHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:337-625-5766
Mailing Address - Street 1:2500 MAPLEWOOD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6100
Mailing Address - Country:US
Mailing Address - Phone:337-625-5766
Mailing Address - Fax:225-208-1056
Practice Address - Street 1:2500 MAPLEWOOD DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6100
Practice Address - Country:US
Practice Address - Phone:337-625-5766
Practice Address - Fax:225-208-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty