Basic Information
Provider Information | |||||||||
NPI: | 1790813889 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GULF COAST TEACHING FAMILY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GULF COAST SOCIAL SERVICES, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2400 EDENBORN AVE | ||||||||
Address2: |   | ||||||||
City: | METAIRIE | ||||||||
State: | LA | ||||||||
PostalCode: | 700011817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5048316561 | ||||||||
FaxNumber: | 5048353156 | ||||||||
Practice Location | |||||||||
Address1: | 5850 FLORIDA BLVD | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708064247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2252010696 | ||||||||
FaxNumber: | 2252011792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2007 | ||||||||
LastUpdateDate: | 09/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GREEN | ||||||||
AuthorizedOfficialFirstName: | WILLIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5048316561 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPA | ||||||||
NPICertificationDate: | 09/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ADC6594 | LA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1534871 | 05 | LA |   | MEDICAID |