Basic Information
Provider Information | |||||||||
NPI: | 1245309046 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INSTITUTE FOR NEUROPSYCHIATRY,APMC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2829 4TH AVE | ||||||||
Address2: | STE. 150 | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706017887 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374777091 | ||||||||
FaxNumber: | 3374744552 | ||||||||
Practice Location | |||||||||
Address1: | 2829 4TH AVE | ||||||||
Address2: | 150 | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706017887 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374777091 | ||||||||
FaxNumber: | 3374744552 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2006 | ||||||||
LastUpdateDate: | 11/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARCHER | ||||||||
AuthorizedOfficialFirstName: | DEWEY | ||||||||
AuthorizedOfficialMiddleName: | DALE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
AuthorizedOfficialTelephone: | 3374777091 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 2084P0800X |   | LA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1945901 | 05 | LA |   | MEDICAID |