Provider Demographics
NPI:1245687383
Name:WELLNESS CLINIC PSYCHIATRY, LLC
Entity type:Organization
Organization Name:WELLNESS CLINIC PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MPAS, PA-C
Authorized Official - Prefix:
Authorized Official - First Name:HALIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-616-0225
Mailing Address - Street 1:P O BOX 636
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546
Mailing Address - Country:US
Mailing Address - Phone:337-616-0225
Mailing Address - Fax:
Practice Address - Street 1:1615 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546
Practice Address - Country:US
Practice Address - Phone:337-616-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty