Healthcare Provider Details

I. General information

NPI: 1609566967
Provider Name (Legal Business Name): DELTA BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4673 EUGENE WARE BLVD
BASTROP LA
71220-1425
US

IV. Provider business mailing address

414 PINE ST
MONROE LA
71201-6228
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-2448
  • Fax: 866-819-6912
Mailing address:
  • Phone: 318-281-2448
  • Fax: 866-819-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY BROCK
Title or Position: DIRECTOR OF REVENUE
Credential:
Phone: 318-281-2448