Provider Demographics
NPI:1144419151
Name:CENTER FOR FAMILY & INDIVIDUAL COUNSELING, INC.
Entity Type:Organization
Organization Name:CENTER FOR FAMILY & INDIVIDUAL COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-443-7711
Mailing Address - Street 1:5615K JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2326
Mailing Address - Country:US
Mailing Address - Phone:318-443-7711
Mailing Address - Fax:318-443-9808
Practice Address - Street 1:5615K JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2326
Practice Address - Country:US
Practice Address - Phone:318-443-7711
Practice Address - Fax:318-443-9808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA474103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5S861Medicare PIN