Provider Demographics
NPI:1750672390
Name:THERAPEUTIC MEDICAL & PSYCHIATRIC SERVICES LLC.
Entity Type:Organization
Organization Name:THERAPEUTIC MEDICAL & PSYCHIATRIC SERVICES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:PRIVITOR
Authorized Official - Last Name:PRIVITOR DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C, PMHNPBC
Authorized Official - Phone:318-816-5116
Mailing Address - Street 1:200 WINTERPARK DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-1106
Mailing Address - Country:US
Mailing Address - Phone:318-396-9712
Mailing Address - Fax:180-051-8423
Practice Address - Street 1:1501 STUBBS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-1106
Practice Address - Country:US
Practice Address - Phone:318-396-9712
Practice Address - Fax:180-051-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-01
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO5002363LF0000X
363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000000000OtherPRIVATE INSURANCE