Provider Demographics
NPI:1093253098
Name:FRESH START FAMILY SUPPORT SERVICES
Entity Type:Organization
Organization Name:FRESH START FAMILY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-422-3547
Mailing Address - Street 1:405 HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2021
Mailing Address - Country:US
Mailing Address - Phone:318-422-3547
Mailing Address - Fax:
Practice Address - Street 1:405 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-2021
Practice Address - Country:US
Practice Address - Phone:318-422-3547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services