Healthcare Provider Details

I. General information

NPI: 1275049611
Provider Name (Legal Business Name): MIIBOSO CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2944 RAY WEILAND DR
BAKER LA
70714-3250
US

IV. Provider business mailing address

2944 RAY WEILAND DR
BAKER LA
70714-3250
US

V. Phone/Fax

Practice location:
  • Phone: 225-993-1535
  • Fax:
Mailing address:
  • Phone: 225-993-1535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3594
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number3594
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3594
License Number StateLA

VIII. Authorized Official

Name: MRS. CHARMAINE STITH
Title or Position: CEO
Credential: LPC-S
Phone: 225-993-1535