Provider Demographics
NPI:1588853048
Name:CENTER FOR PSYCHOLOGICAL TRAUMA, LLC
Entity Type:Organization
Organization Name:CENTER FOR PSYCHOLOGICAL TRAUMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-221-4455
Mailing Address - Street 1:820 JORDAN ST
Mailing Address - Street 2:STE. 570
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4518
Mailing Address - Country:US
Mailing Address - Phone:318-221-4455
Mailing Address - Fax:318-221-4459
Practice Address - Street 1:820 JORDAN ST
Practice Address - Street 2:STE. 570
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4518
Practice Address - Country:US
Practice Address - Phone:318-221-4455
Practice Address - Fax:318-221-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA88071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR75Medicare PIN