Basic Information
| Provider Information | |||||||||
| NPI: | 1770753303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION PARISH MENTAL HEALTH AND ADDICTIVE DISORDERS CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 S. EAST ASCENSION COMPLEX AVENUE | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256215775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1112 S. EAST ASCENSION COMPLEX AVENUE | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256215775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | MITTENDORF | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2256211113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D., LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 260A | LA | Y | Agencies | Community/Behavioral Health |
No ID Information.