Basic Information
| Provider Information | |||||||||
| NPI: | 1407079163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRIEF RECOVERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4919 JAMESTOWN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708083228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259246621 | ||||||||
| FaxNumber: | 2259246627 | ||||||||
| Practice Location | |||||||||
| Address1: | 4919 JAMESTOWN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708083228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259246621 | ||||||||
| FaxNumber: | 2259246627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VILAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2259246621 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1041C0700X | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.