Basic Information
| Provider Information | |||||||||
| NPI: | 1316474356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLOW BEND FAMILY SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PAUL GANIER, LPC, PHD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1536 | ||||||||
| Address2: | |||||||||
| City: | MANDEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704701536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856356943 | ||||||||
| FaxNumber: | 9856356948 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 ABBY RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703016020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854480764 | ||||||||
| FaxNumber: | 9854481912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | GANIER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9854480764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.