Provider Demographics
NPI:1639511256
Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Other - Org Name:BASTROP BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE PROGRAM SPECIALIST B
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-362-3270
Mailing Address - Street 1:451 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-3829
Mailing Address - Country:US
Mailing Address - Phone:318-283-0868
Mailing Address - Fax:318-283-0875
Practice Address - Street 1:451 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3829
Practice Address - Country:US
Practice Address - Phone:318-283-0868
Practice Address - Fax:318-283-0875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-24
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782906261QM0801X
LA91261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1750051Medicaid