Basic Information
| Provider Information | |||||||||
| NPI: | 1447512512 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEFUL ALTERNATIVES COUNSELING AND THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29372 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186708898 | ||||||||
| FaxNumber: | 3183003772 | ||||||||
| Practice Location | |||||||||
| Address1: | 5902 BUNCOMBE RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711294004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186708898 | ||||||||
| FaxNumber: | 3183003772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | TERRY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | THEODORE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS OPERATION/ MHP | ||||||||
| AuthorizedOfficialTelephone: | 3186708898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | BH0012168 | 01 | LA | LOUISIANA DEPARTMENT OF HEALTH: BEHAVIORAL HEALTH | OTHER | BH0011860 | 01 | LA | LOUISIANA DEPARTMENT OF HEALTH: BEHAVIORAL HEALTH LICENSE | OTHER |