Basic Information
| Provider Information | |||||||||
| NPI: | 1457822751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SULPHUR BEHAVIORAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2651 E NAPOLEON ST | ||||||||
| Address2: | |||||||||
| City: | SULPHUR | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706633707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374753100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2651 E NAPOLEON ST | ||||||||
| Address2: | |||||||||
| City: | SULPHUR | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374753100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2018 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3374758701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NRHCMC | ||||||||
| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.