Provider Demographics
NPI:1689274698
Name:PEGASUS BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:PEGASUS BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-373-4385
Mailing Address - Street 1:116 CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4127
Mailing Address - Country:US
Mailing Address - Phone:985-224-0412
Mailing Address - Fax:985-202-9331
Practice Address - Street 1:400 MARINERS PLAZA DR STE 409D
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-6849
Practice Address - Country:US
Practice Address - Phone:985-224-0412
Practice Address - Fax:985-202-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6961OtherSTATE LICENSE