Provider Demographics
NPI:1821358300
Name:IMPACT BEHAVIOR HEALTH SERVICES LLC.
Entity Type:Organization
Organization Name:IMPACT BEHAVIOR HEALTH SERVICES LLC.
Other - Org Name:IMPACT BEHAVIOR HEALTYH SERRVICES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER DEGREE
Authorized Official - Phone:504-304-4097
Mailing Address - Street 1:2439 MANHATTAN BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-5469
Mailing Address - Country:US
Mailing Address - Phone:504-304-4097
Mailing Address - Fax:
Practice Address - Street 1:2439 MANHATTAN BLVD STE 402
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-5469
Practice Address - Country:US
Practice Address - Phone:504-662-7617
Practice Address - Fax:504-218-7962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-18
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health