Provider Demographics
NPI:1164973319
Name:CLC BEHAVIORAL LLC
Entity Type:Organization
Organization Name:CLC BEHAVIORAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUERVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:337-233-2400
Mailing Address - Street 1:PO BOX 82281
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-2281
Mailing Address - Country:US
Mailing Address - Phone:337-233-2400
Mailing Address - Fax:337-232-3656
Practice Address - Street 1:800 KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4210
Practice Address - Country:US
Practice Address - Phone:337-233-2400
Practice Address - Fax:337-232-3656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3037842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX ID