Basic Information
| Provider Information | |||||||||
| NPI: | 1144674698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND REHABILITATION & RESOURCE CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIND REHABILITATION & RESOURCE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 LINE AVE # 135 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
| FaxNumber: | 3188281626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 LINE AVE # 135 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188281455 | ||||||||
| FaxNumber: | 3188281626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANDOSIA | ||||||||
| AuthorizedOfficialFirstName: | LATOYTA | ||||||||
| AuthorizedOfficialMiddleName: | DANIELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | MHS | ||||||||
| AuthorizedOfficialTelephone: | 3188281455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LA | Y | Agencies | Community/Behavioral Health |
No ID Information.