Provider Demographics
NPI:1578822177
Name:BOYS AND GIRLS VILLAGES FOUNDATION
Entity Type:Organization
Organization Name:BOYS AND GIRLS VILLAGES FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAYANCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATHIEU,
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:337-436-7553
Mailing Address - Street 1:7378 HIGHWAY 90 E
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70615-4803
Mailing Address - Country:US
Mailing Address - Phone:337-436-7553
Mailing Address - Fax:337-436-8291
Practice Address - Street 1:7378 HIGHWAY 90 E
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70615-4803
Practice Address - Country:US
Practice Address - Phone:337-436-7553
Practice Address - Fax:337-436-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8998320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness