Provider Demographics
NPI:1184913451
Name:PSYCHIATRIC SOLUTIONS LLC
Entity type:Organization
Organization Name:PSYCHIATRIC SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROMMELAND GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:985-209-0953
Mailing Address - Street 1:929 BAYOU DULARGE RD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7614
Mailing Address - Country:US
Mailing Address - Phone:985-209-0953
Mailing Address - Fax:941-295-7336
Practice Address - Street 1:1101 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4957
Practice Address - Country:US
Practice Address - Phone:985-209-0953
Practice Address - Fax:941-295-7336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO5139261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
5DY12Medicare PIN