Provider Demographics
NPI:1578169306
Name:PELICAN BAYOU COUNSELING AGENCY-TEXAS
Entity Type:Organization
Organization Name:PELICAN BAYOU COUNSELING AGENCY-TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-470-1632
Mailing Address - Street 1:9403 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3815
Mailing Address - Country:US
Mailing Address - Phone:318-861-8938
Mailing Address - Fax:
Practice Address - Street 1:1111 W MOCKINGBIRD LN STE 7-2
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-5028
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PELICAN BAYOU COUNSELING AGENCY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-08
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health