Provider Demographics
NPI:1205354974
Name:MISS-LOU ADDICTION CLINIC
Entity type:Organization
Organization Name:MISS-LOU ADDICTION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BSW
Authorized Official - Phone:601-442-0270
Mailing Address - Street 1:1000 CHINABERRY DR STE 903
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:318-459-6795
Mailing Address - Fax:
Practice Address - Street 1:525 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2001
Practice Address - Country:US
Practice Address - Phone:601-442-0270
Practice Address - Fax:888-981-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1112895251S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1124215215OtherCLINICAL DIRECTOR