Provider Demographics
NPI:1306950449
Name:COCO, PHILLIP MICHAEL (LAC)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:COCO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOREAUVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71355-2502
Mailing Address - Country:US
Mailing Address - Phone:318-487-5191
Mailing Address - Fax:318-487-5184
Practice Address - Street 1:401 RAINBOW DR UNIT 6
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6979
Practice Address - Country:US
Practice Address - Phone:318-484-2168
Practice Address - Fax:318-487-5453
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC #798101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG9759OtherBLUECROSSBLUESHIELD
LA5DL60Medicare PIN