Basic Information
| Provider Information | |||||||||
| NPI: | 1205354974 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISS-LOU ADDICTION CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 903 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184596795 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 ALEXANDER ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712512001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014420270 | ||||||||
| FaxNumber: | 8889812815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | MONA | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6014420270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, BSW | ||||||||
| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1112895 | MS | N | Agencies | Community/Behavioral Health | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.