Healthcare Provider Details

I. General information

NPI: 1790236586
Provider Name (Legal Business Name): HOLISTIC BEHAVIORAL HEALTH SERVICES OF LOUISIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 09/06/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2156 WOODDALE BLVD STE 750
BATON ROUGE LA
70806-1404
US

IV. Provider business mailing address

2156 WOODDALE BLVD STE 750
BATON ROUGE LA
70806-1404
US

V. Phone/Fax

Practice location:
  • Phone: 225-371-2945
  • Fax: 225-930-8059
Mailing address:
  • Phone: 225-371-2945
  • Fax: 225-930-8059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number510417
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number510417
License Number StateLA

VIII. Authorized Official

Name: TOMMIE JEROME DYER
Title or Position: CEO/OWNER
Credential:
Phone: 225-371-2945