Basic Information
| Provider Information | |||||||||
| NPI: | 1457789802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LCBHC CHILDRENS OUTREACH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3505 5TH AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706072156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374753100 | ||||||||
| FaxNumber: | 3374753105 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 5TH AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706072156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374753100 | ||||||||
| FaxNumber: | 3374753105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2013 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGEE | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3374753100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LAC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 95 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1710041 | 05 | LA | MEDICAID |