Provider Demographics
NPI:1174162762
Name:LAKE CHARLES ADDICTION AND WELLNESS CENTER
Entity type:Organization
Organization Name:LAKE CHARLES ADDICTION AND WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:337-513-6121
Mailing Address - Street 1:2789 CROWN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-8135
Mailing Address - Country:US
Mailing Address - Phone:337-513-6121
Mailing Address - Fax:
Practice Address - Street 1:315 ALAMO ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8528
Practice Address - Country:US
Practice Address - Phone:337-513-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-30
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1184754723Medicaid
LA1457807828Medicaid
LA1447703251Medicaid