Provider Demographics
NPI:1851391148
Name:OUR LADY OF THE LAKE
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE
Other - Org Name:FAMILY CENTER FOR MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-4251
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 6000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-8648
Mailing Address - Fax:225-765-7898
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 6000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-8648
Practice Address - Fax:225-765-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03085883Medicaid
LA1446751Medicaid
LA5D497Medicare PIN