Basic Information
Provider Information | |||||||||
NPI: | 1992950828 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METROPOLITAN CIRCLES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3510 LINWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711034512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186364194 | ||||||||
FaxNumber: | 3186364196 | ||||||||
Practice Location | |||||||||
Address1: | 90 MELROSE AVE | ||||||||
Address2: |   | ||||||||
City: | NATCHITOCHES | ||||||||
State: | LA | ||||||||
PostalCode: | 714575926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182383197 | ||||||||
FaxNumber: | 3182383199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2008 | ||||||||
LastUpdateDate: | 08/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALHOUN-BEAUDION | ||||||||
AuthorizedOfficialFirstName: | TAWANA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3186364194 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   | LA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1885029 | 05 | LA |   | MEDICAID |