Provider Demographics
NPI:1861657421
Name:SIGNS & WONDERS COMMUNITY MENTAL HEALTH CENTER LLC
Entity Type:Organization
Organization Name:SIGNS & WONDERS COMMUNITY MENTAL HEALTH CENTER LLC
Other - Org Name:SOUTHEAST PROFESSIONAL HEALTH GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THANE
Authorized Official - Middle Name:BATTISTE
Authorized Official - Last Name:PAINIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-687-9902
Mailing Address - Street 1:PO BOX 291
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70765-0291
Mailing Address - Country:US
Mailing Address - Phone:225-687-9902
Mailing Address - Fax:225-687-9903
Practice Address - Street 1:25341 HWY 1 SOUTH
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764
Practice Address - Country:US
Practice Address - Phone:225-687-9902
Practice Address - Fax:225-687-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA194709261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA194709Medicare PIN