Basic Information
| Provider Information | |||||||||
| NPI: | 1023376498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LSU HEALTHCARE NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LSU BEHAVIORAL SCIENCES CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 POYDRAS ST | ||||||||
| Address2: | SUITE 1640 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701121221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121100 | ||||||||
| FaxNumber: | 5044121530 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 CHESTNUT ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701152443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121580 | ||||||||
| FaxNumber: | 5044121530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOULD | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT III | ||||||||
| AuthorizedOfficialTelephone: | 5049039213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LSU HEALTHCARE NETWORK | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.