Provider Demographics
NPI:1417601394
Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Other - Org Name:TALLULAH BEHAVIORAL HEALTH CLINIC-MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE PROGRAM SPECIALIST B
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-362-3270
Mailing Address - Street 1:1012 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-5216
Mailing Address - Country:US
Mailing Address - Phone:318-574-1713
Mailing Address - Fax:318-574-2299
Practice Address - Street 1:1012 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-5216
Practice Address - Country:US
Practice Address - Phone:318-574-1713
Practice Address - Fax:318-574-2299
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710351Medicaid