Provider Demographics
NPI:1629099502
Name:LOUISIANA PSYCHIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:LOUISIANA PSYCHIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-927-4504
Mailing Address - Street 1:5225 CAPITOL HEIGHTS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6066
Mailing Address - Country:US
Mailing Address - Phone:225-927-4504
Mailing Address - Fax:
Practice Address - Street 1:5225 CAPITOL HEIGHTS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6066
Practice Address - Country:US
Practice Address - Phone:225-927-4504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1443018Medicaid
LA1443018Medicaid