Basic Information
Provider Information | |||||||||
NPI: | 1174060925 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLDSON | ||||||||
FirstName: | IVAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 66558 | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708966558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2259251906 | ||||||||
FaxNumber: | 2253625314 | ||||||||
Practice Location | |||||||||
Address1: | 4615 GOVERNMENT ST | ||||||||
Address2: | BUILDING 2 | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708065922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2259251906 | ||||||||
FaxNumber: | 2253625314 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2017 | ||||||||
LastUpdateDate: | 08/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YA0400X | 1512 | LA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X |   |   | N |   |   |   |   |
No ID Information.