Basic Information
| Provider Information | |||||||||
| NPI: | 1609247907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COGNITIVE DEVELOPMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 FELICIA AVE | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712828203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185741232 | ||||||||
| FaxNumber: | 3185748646 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 FELICIA AVE | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712828203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185741232 | ||||||||
| FaxNumber: | 3185748646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2015 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | ADRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3186147644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2930 | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.