Provider Demographics
NPI:1952449118
Name:IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
Other - Org Name:LAKE CHARLES BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:NRHCMC
Authorized Official - Phone:337-475-8701
Mailing Address - Street 1:4105 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4603
Mailing Address - Country:US
Mailing Address - Phone:337-475-8022
Mailing Address - Fax:337-475-8054
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-8022
Practice Address - Fax:337-475-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA95207QA0505X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710041Medicaid
LA1710041Medicaid