Basic Information
| Provider Information | |||||||||
| NPI: | 1922117514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARISH OF ASCENSION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ASCENSION COUNSELING AND SUBSTANCE ABUSE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 E ASCENSION COMPLEX BLVD | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256215775 | ||||||||
| FaxNumber: | 2256442846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 E ASCENSION COMPLEX BLVD | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256215775 | ||||||||
| FaxNumber: | 2256442846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITTENDORF | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2256215775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D, LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | FS 3361 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.