Basic Information
| Provider Information | |||||||||
| NPI: | 1679929277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROMISE | ||||||||
| FirstName: | JANICE | ||||||||
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| Credential: | A.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 244 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713730244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188409570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1705 FELICIA AVE | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712828203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185741232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.