Provider Demographics
NPI:1083073217
Name:MIND REHABILITATION & RESOURCE CENTER
Entity Type:Organization
Organization Name:MIND REHABILITATION & RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMIQUE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-780-2828
Mailing Address - Street 1:2923 OAK FOREST LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5802
Mailing Address - Country:US
Mailing Address - Phone:318-780-2828
Mailing Address - Fax:
Practice Address - Street 1:1513 LINE AVE STE 135
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4621
Practice Address - Country:US
Practice Address - Phone:318-828-1455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19320000X/101YM0800X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health