Provider Demographics
NPI:1265267819
Name:SOUTHERN PSYCHIATRIC & MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:SOUTHERN PSYCHIATRIC & MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:BREALON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIRETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-635-6943
Mailing Address - Street 1:PO BOX 1536
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1536
Mailing Address - Country:US
Mailing Address - Phone:985-635-6943
Mailing Address - Fax:985-231-6733
Practice Address - Street 1:8175 PARK AVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-3438
Practice Address - Country:US
Practice Address - Phone:985-635-6943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty