Provider Demographics
NPI:1821527011
Name:THACKER, ERIC
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ASHFORD DR APT 511
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7851
Mailing Address - Country:US
Mailing Address - Phone:318-557-5953
Mailing Address - Fax:
Practice Address - Street 1:622 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6211
Practice Address - Country:US
Practice Address - Phone:318-398-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7145101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor