Provider Demographics
NPI:1992467641
Name:SOUTHERN PSYCHIATRIC SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHERN PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-480-7800
Mailing Address - Street 1:2829 4TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7897
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7490 BUCKSKIN DR
Practice Address - Street 2:
Practice Address - City:IOWA
Practice Address - State:LA
Practice Address - Zip Code:70647-4429
Practice Address - Country:US
Practice Address - Phone:337-540-7436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA12345Medicaid