Provider Demographics
NPI:1154461937
Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:ALLIED HEALTH CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLIN MGMT SYSTEM
Authorized Official - Prefix:
Authorized Official - First Name:REVA
Authorized Official - Middle Name:MATTHIEW
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:318-813-2962
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2962
Mailing Address - Fax:
Practice Address - Street 1:3735 BLAIR DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4601
Practice Address - Country:US
Practice Address - Phone:318-813-2962
Practice Address - Fax:318-813-2981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X, 235Z00000X, 237600000X, 332S00000X, 104100000X, 225100000X
LA261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid