Basic Information
| Provider Information | |||||||||
| NPI: | 1821421686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST LOUISIANA HUMAN SERVICES DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHREVEPORT BEHAVIORAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 N HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | 3186765021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 N HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | 3186765021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2013 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3188623067 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2203782546 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 2203782546 | 01 | LA | BEHAVIORAL HEALTH SERVICE PROVIDER | OTHER | 1710083 | 05 | LA | MEDICAID |