Provider Demographics
NPI:1114550001
Name:BEACON BEHAVIORAL HOSPITAL LLC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL HOSPITAL LLC
Other - Org Name:BEACON BEHAVIORAL OUTPATIENT - HAMMOND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4040
Mailing Address - Street 1:4601 BLUEBONNET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9656
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:42382 DELUXE PLZ STE 34
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1236
Practice Address - Country:US
Practice Address - Phone:985-956-7378
Practice Address - Fax:985-956-7381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
194102OtherMEDICARE
LA2184164Medicaid