Basic Information
| Provider Information | |||||||||
| NPI: | 1356493530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM REHAB SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30826 LINDER RD | ||||||||
| Address2: | |||||||||
| City: | DENHAM SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707268507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256657878 | ||||||||
| FaxNumber: | 2256657856 | ||||||||
| Practice Location | |||||||||
| Address1: | 30826 LINDER RD | ||||||||
| Address2: | |||||||||
| City: | DENHAM SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707268507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256657878 | ||||||||
| FaxNumber: | 2256657856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MINER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2256657878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1548839 | LA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1548839 | 05 | LA | MEDICAID | 1989151 | 05 | LA | MEDICAID |