Basic Information
| Provider Information | |||||||||
| NPI: | 1578574471 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CYPRESS GROVE BEHAVIORAL HEALTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERIDIAN BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN STREET | ||||||||
| Address2: | SUITE 250, CONTRACTING/CREDENTIALING | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267575 | ||||||||
| FaxNumber: | 6124542430 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186998819 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6123267575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | LA | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 159664125 | 05 | AR | MEDICAID | 1709581 | 05 | LA | MEDICAID |