Provider Demographics
NPI:1063830727
Name:ECLECTIC COGNITIVE BEHAVIORAL CENTER, LLC
Entity Type:Organization
Organization Name:ECLECTIC COGNITIVE BEHAVIORAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, PHD
Authorized Official - Phone:225-924-2800
Mailing Address - Street 1:1733 WOODDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1508
Mailing Address - Country:US
Mailing Address - Phone:225-924-2800
Mailing Address - Fax:225-924-2800
Practice Address - Street 1:1733 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1508
Practice Address - Country:US
Practice Address - Phone:225-924-2800
Practice Address - Fax:225-924-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3676251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600559886Medicaid