Basic Information
| Provider Information | |||||||||
| NPI: | 1174036156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSE OF HOPE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHY MINDS INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 W JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712204543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182393890 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 222 W HICKORY AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712204552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182393890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 11/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3182393890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHY MINDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 2203783395 | LA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 465660466 | 05 | LA | MEDICAID |