Provider Demographics
NPI:1063000750
Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL MGMT SYSTEM
Authorized Official - Prefix:
Authorized Official - First Name:REVA
Authorized Official - Middle Name:LATISHA
Authorized Official - Last Name:MATTHIEW
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:318-813-2962
Mailing Address - Street 1:1450 CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4204
Mailing Address - Country:US
Mailing Address - Phone:318-813-2962
Mailing Address - Fax:318-813-2975
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4204
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty