Provider Demographics
NPI:1821421686
Name:NORTHWEST LOUISIANA HUMAN SERVICES DISTRICT
Entity Type:Organization
Organization Name:NORTHWEST LOUISIANA HUMAN SERVICES DISTRICT
Other - Org Name:SHREVEPORT BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-862-3067
Mailing Address - Street 1:1310 N HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6516
Mailing Address - Country:US
Mailing Address - Phone:318-676-5111
Mailing Address - Fax:318-676-5021
Practice Address - Street 1:1310 N HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6516
Practice Address - Country:US
Practice Address - Phone:318-676-5111
Practice Address - Fax:318-676-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782546261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203782546OtherBEHAVIORAL HEALTH SERVICE PROVIDER
LA1710083Medicaid
LA2203782546OtherBEHAVIORAL HEALTH SERVICE PROVIDER