Healthcare Provider Details

I. General information

NPI: 1225782196
Provider Name (Legal Business Name): NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 E MADISON AVE
BASTROP LA
71220-3829
US

IV. Provider business mailing address

450 E PINE STREET
BASTROP LA
71220-3840
US

V. Phone/Fax

Practice location:
  • Phone: 318-283-0868
  • Fax: 318-556-7090
Mailing address:
  • Phone: 318-283-0868
  • Fax: 318-283-0875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OCTAVIA GREEN
Title or Position: ADMINISTRATIVE PROGRAM MANAGER
Credential:
Phone: 318-362-3270