Basic Information
| Provider Information | |||||||||
| NPI: | 1275062051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | LEURAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 OLD STERLINGTON RD UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | STERLINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712803529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174128264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 STUBBS AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185124997 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2017 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 006032576 | LA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | 1275062051 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1497113559 | 05 | LA | MEDICAID | 810754289 | 05 | LA | MEDICAID |