Provider Demographics
NPI:1669846879
Name:IMPACT BEHAVIOR HEALTH SERVICE
Entity Type:Organization
Organization Name:IMPACT BEHAVIOR HEALTH SERVICE
Other - Org Name:IMPACT BEHAVIOR HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER
Authorized Official - Phone:504-329-3755
Mailing Address - Street 1:1406 ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70116-1803
Mailing Address - Country:US
Mailing Address - Phone:504-304-4097
Mailing Address - Fax:504-218-7962
Practice Address - Street 1:1406 ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70116-1803
Practice Address - Country:US
Practice Address - Phone:504-304-4097
Practice Address - Fax:504-218-7962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPACT BEHAVIOR HEALTH SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-26
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health