Provider Demographics
NPI:1457789802
Name:IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
Entity Type:Organization
Organization Name:IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
Other - Org Name:LCBHC CHILDRENS OUTREACH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:337-475-3100
Mailing Address - Street 1:3505 5TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-2156
Mailing Address - Country:US
Mailing Address - Phone:337-475-3100
Mailing Address - Fax:337-475-3105
Practice Address - Street 1:3505 5TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-2156
Practice Address - Country:US
Practice Address - Phone:337-475-3100
Practice Address - Fax:337-475-3105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL CALCASIEU HUMAN SERVICES AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA95261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710041Medicaid