Basic Information
| Provider Information | |||||||||
| NPI: | 1578169306 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PELICAN BAYOU COUNSELING AGENCY-TEXAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9403 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188618938 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 W MOCKINGBIRD LN STE 7-2 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752475028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188618938 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2020 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | JEWITT | ||||||||
| AuthorizedOfficialFirstName: | BRITTNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3184701632 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PELICAN BAYOU COUNSELING AGENCY INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.