Basic Information
Provider Information | |||||||||
NPI: | 1700211299 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST LOUISIANA HUMAN SERVICES DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANY BEHAVIORAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 265 HIGHLAND DR | ||||||||
Address2: |   | ||||||||
City: | MANY | ||||||||
State: | LA | ||||||||
PostalCode: | 714493717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182564119 | ||||||||
FaxNumber: | 3182564171 | ||||||||
Practice Location | |||||||||
Address1: | 265 HIGHLAND DR | ||||||||
Address2: |   | ||||||||
City: | MANY | ||||||||
State: | LA | ||||||||
PostalCode: | 714493717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182564119 | ||||||||
FaxNumber: | 3182564171 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2013 | ||||||||
LastUpdateDate: | 12/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTSON | ||||||||
AuthorizedOfficialFirstName: | CAROL | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 3188623067 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2203782546-C | LA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 1710083 | 05 | LA |   | MEDICAID | 2203782546-C | 01 | LA | BEHAVIORAL HEALTH SERVICE PROVIDER | OTHER |