Provider Demographics
NPI:1558804740
Name:RED RIVER THERAPEUTIC SOULUTIONS
Entity Type:Organization
Organization Name:RED RIVER THERAPEUTIC SOULUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONSAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:VONETTA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:318-402-7789
Mailing Address - Street 1:7000 RED FOX TRL APT 237
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3546
Mailing Address - Country:US
Mailing Address - Phone:318-423-7963
Mailing Address - Fax:
Practice Address - Street 1:7000 RED FOX TRL APT 237
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3546
Practice Address - Country:US
Practice Address - Phone:318-423-7963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health