Basic Information
| Provider Information | |||||||||
| NPI: | 1083194393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLTC-LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048272701 | ||||||||
| FaxNumber: | 5048272715 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048272701 | ||||||||
| FaxNumber: | 5048272715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOGILLES | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | MARGARET | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5048272701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2136593 | 05 | LA | MEDICAID |