1558662338 NPI number — GRACE BEHAVIORAL HEALTH SOLUTIONS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558662338 NPI number — GRACE BEHAVIORAL HEALTH SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE BEHAVIORAL HEALTH SOLUTIONS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558662338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2924 KNIGHT ST
Provider Second Line Business Mailing Address:
SUITE 414
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71105-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-861-7340
Provider Business Mailing Address Fax Number:
318-861-7390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2924 KNIGHT ST
Provider Second Line Business Practice Location Address:
SUITE 414
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-861-7340
Provider Business Practice Location Address Fax Number:
318-861-7390
Provider Enumeration Date:
11/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LAW
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
PSYCHIATRIST
Authorized Official Telephone Number:
318-453-4084

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  MD199987 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com