Basic Information
| Provider Information | |||||||||
| NPI: | 1518695519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CENTER FOR CHILDREN AND FAMILIES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183980945 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183980945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2022 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | THORNTON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3183980945 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D., LPC, LMFT | ||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1813249 | 05 | LA | MEDICAID |