Basic Information
Provider Information | |||||||||
NPI: | 1184741902 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRINITY COUNSELING CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2150 GENERAL PERSHING STREET | ||||||||
Address2: |   | ||||||||
City: | MANDEVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 70448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9856745155 | ||||||||
FaxNumber: | 9856745156 | ||||||||
Practice Location | |||||||||
Address1: | 2150 GENERAL PERSHING ST | ||||||||
Address2: |   | ||||||||
City: | MANDEVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 704485125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9856745155 | ||||||||
FaxNumber: | 9856745156 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2007 | ||||||||
LastUpdateDate: | 04/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CROWLEY | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9856745155 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ABA 36364795K | LA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1120804 | 05 | LA |   | MEDICAID |