Provider Demographics
NPI:1598376907
Name:THERIOT HANOVER, COLIN BREA (MED, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:BREA
Last Name:THERIOT HANOVER
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31301 LA HWY 3143
Mailing Address - Street 2:
Mailing Address - City:GUEYDAN
Mailing Address - State:LA
Mailing Address - Zip Code:70542-5652
Mailing Address - Country:US
Mailing Address - Phone:337-230-3842
Mailing Address - Fax:
Practice Address - Street 1:850 KALISTE SALOOM RD STE 219
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4230
Practice Address - Country:US
Practice Address - Phone:337-504-4974
Practice Address - Fax:337-456-2434
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3485761Medicaid