Basic Information
| Provider Information | |||||||||
| NPI: | 1518208941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ARLENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PEER SUPPORT LIASON | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 402 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706553519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376393001 | ||||||||
| FaxNumber: | 3376393008 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706553519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376393001 | ||||||||
| FaxNumber: | 3376393008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2013 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LA | N | Behavioral Health & Social Service Providers | Counselor | 175T00000X | LA | Y |
ID Information
| ID | Type | State | Issuer | Description | 1710580 | 05 | LA | MEDICAID |