Provider Demographics
| NPI: | 1578091104 |
|---|---|
| Name: | LONGBRANCH OUTPATIENT RECOVERY, LLC |
| Entity Type: | Organization |
| Organization Name: | LONGBRANCH OUTPATIENT RECOVERY, LLC |
| Other - Org Name: | LONGBRANCH WELLNESS CENTER |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | EMILY |
| Authorized Official - Middle Name: | ELIZABETH |
| Authorized Official - Last Name: | MEYERS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | LPC |
| Authorized Official - Phone: | 920-309-0541 |
| Mailing Address - Street 1: | 406 N. FLORDIA STREET |
| Mailing Address - Street 2: | STE 1 |
| Mailing Address - City: | COVINGTON |
| Mailing Address - State: | LA |
| Mailing Address - Zip Code: | 70433 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 504-267-9960 |
| Mailing Address - Fax: | 504-267-9979 |
| Practice Address - Street 1: | 406 N. FLORDIA STREET |
| Practice Address - Street 2: | SUITE #1 |
| Practice Address - City: | COVINGTON |
| Practice Address - State: | LA |
| Practice Address - Zip Code: | 70433 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 504-635-3535 |
| Practice Address - Fax: | 504-267-9979 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2017-05-26 |
| Last Update Date: | 2024-01-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QR0800X | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TP0016X | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | ||
| No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Group - Multi-Specialty |
