Basic Information
Provider Information | |||||||||
NPI: | 1225183742 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEPARTMENT OF HEALTH & HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANY BEHAVIORAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 265 HIGHLAND DRIVE | ||||||||
Address2: |   | ||||||||
City: | MANY | ||||||||
State: | LA | ||||||||
PostalCode: | 714493717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182564119 | ||||||||
FaxNumber: | 3182564171 | ||||||||
Practice Location | |||||||||
Address1: | 265 HIGHLAND DRIVE | ||||||||
Address2: |   | ||||||||
City: | MANY | ||||||||
State: | LA | ||||||||
PostalCode: | 714493717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182564119 | ||||||||
FaxNumber: | 3182564171 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2007 | ||||||||
LastUpdateDate: | 07/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | ALLIE | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | DIR. OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3186765160 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 93 | LA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 1710601 | 05 | LA |   | MEDICAID |