Provider Demographics
NPI:1457710493
Name:DIVINE IMPACT BEHAVIORAL SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:DIVINE IMPACT BEHAVIORAL SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:PASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-330-0788
Mailing Address - Street 1:1799 STUMPF BLVD
Mailing Address - Street 2:BUILDING 5 SUITE 1
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-3950
Mailing Address - Country:US
Mailing Address - Phone:504-330-0788
Mailing Address - Fax:
Practice Address - Street 1:1799 STUMPF BLVD
Practice Address - Street 2:BUILDING 5 SUITE 1
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-330-0788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA41056835251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health