Provider Demographics
NPI:1255941902
Name:NEW LEAF BEHAVIORAL HEALTH CLINICIANS, LLC
Entity type:Organization
Organization Name:NEW LEAF BEHAVIORAL HEALTH CLINICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HORATIO
Authorized Official - Middle Name:ACQUINALDO
Authorized Official - Last Name:MILLIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-476-1338
Mailing Address - Street 1:2905 FISKE STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8550
Mailing Address - Country:US
Mailing Address - Phone:337-476-1338
Mailing Address - Fax:
Practice Address - Street 1:2905 FISKE STREET
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8550
Practice Address - Country:US
Practice Address - Phone:337-476-1338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW LEAF BEHAVIORAL HEALTH CLINICIAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1049085Medicaid