Provider Demographics
NPI:1558994434
Name:BEACON BEHAVIORAL HOSPITAL NORTHSHORE, LLC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL HOSPITAL NORTHSHORE, LLC
Other - Org Name:BEACON BEHAVIORAL OUTPATIENT - BOGALUSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4040
Mailing Address - Street 1:4601 BLUEBONNET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9656
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:1640 S COLUMBIA ST STE B
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-5800
Practice Address - Country:US
Practice Address - Phone:985-735-1750
Practice Address - Fax:985-735-1752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL HOSPITAL NORTHSHORE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08036043Medicaid
194080OtherMEDICARE
LA1709549Medicaid