Provider Demographics
NPI:1033541230
Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Other - Org Name:RUSTON BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE PROGRAM SPECIALIST B
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-362-3270
Mailing Address - Street 1:901 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5960
Mailing Address - Country:US
Mailing Address - Phone:318-251-4125
Mailing Address - Fax:318-251-5000
Practice Address - Street 1:901 WHITE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5960
Practice Address - Country:US
Practice Address - Phone:318-251-4125
Practice Address - Fax:318-251-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
LA2203781812261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710342Medicaid
LA2203785977OtherSTATE LICENSE