Basic Information
| Provider Information | |||||||||
| NPI: | 1922344621 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHANGING BEHAVIOR SERVICES OF MINDEN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78776 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711378776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183716707 | ||||||||
| FaxNumber: | 3183778164 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 HOMER RD | ||||||||
| Address2: | |||||||||
| City: | MINDEN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710552909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183716707 | ||||||||
| FaxNumber: | 3183778164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 12/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3186175869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 251S00000X | 10334080#B4P83 | LA | Y | Agencies | Community/Behavioral Health |
No ID Information.