Basic Information
| Provider Information | |||||||||
| NPI: | 1184890337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHREVEPORT MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 N HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | 3186765077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 N HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | 3186765077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETTERWAY | ||||||||
| AuthorizedOfficialFirstName: | ROBENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MHC MANAGER 4 | ||||||||
| AuthorizedOfficialTelephone: | 3186765111 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF LOUISIANA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.