Basic Information
| Provider Information | |||||||||
| NPI: | 1124247945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COGNITIVE DEVELOPMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7563 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712117563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183871304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1811 ROSELAWN AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186518078 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 10/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3183871304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 1470911 | 05 | LA | MEDICAID |