Provider Demographics
NPI:1801062054
Name:SHREVEPORT MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:SHREVEPORT MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE3
Authorized Official - Prefix:MS
Authorized Official - First Name:CLEONA
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-676-5135
Mailing Address - Street 1:1310 N HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6516
Mailing Address - Country:US
Mailing Address - Phone:318-676-5135
Mailing Address - Fax:
Practice Address - Street 1:1310 N HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6516
Practice Address - Country:US
Practice Address - Phone:318-676-5135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPT HEALTH AND HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA79957251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health