Basic Information
| Provider Information | |||||||||
| NPI: | 1316408693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC TRANSFORMATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 UNIVERSITY AVE # 105 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712099000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182379948 | ||||||||
| FaxNumber: | 3183258749 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 UNIVERSITY AVE # 105 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712099000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182379948 | ||||||||
| FaxNumber: | 3183258749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | ALETHA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PROFESSIONAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 3182379948 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5010426 | 05 | LA | MEDICAID |