Provider Demographics
NPI:1255759148
Name:FELICIANAS' YOUTH OF DISTINCTION BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:FELICIANAS' YOUTH OF DISTINCTION BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:SPANN
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:225-244-7026
Mailing Address - Street 1:10105 PLANK RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-3707
Mailing Address - Country:US
Mailing Address - Phone:225-244-7026
Mailing Address - Fax:225-244-7028
Practice Address - Street 1:10105 PLANK RD STE A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3707
Practice Address - Country:US
Practice Address - Phone:225-244-7026
Practice Address - Fax:225-244-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600925226Medicaid