Provider Demographics
NPI:1396024303
Name:STATE OF LA/DHH/OBH
Entity Type:Organization
Organization Name:STATE OF LA/DHH/OBH
Other - Org Name:LAKE CHARLES BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:TUTSON
Authorized Official - Last Name:COTLONE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:337-475-4930
Mailing Address - Street 1:4105 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4603
Mailing Address - Country:US
Mailing Address - Phone:337-475-4930
Mailing Address - Fax:
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA870077251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care