Healthcare Provider Details

I. General information

NPI: 1699767699
Provider Name (Legal Business Name): BEACON BEHAVIORAL HEALTH-BATON ROUGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 COLONIAL DR
BATON ROUGE LA
70806-6505
US

IV. Provider business mailing address

9938 AIRLINE HWY SUITE 200
BATON ROUGE LA
70816-8100
US

V. Phone/Fax

Practice location:
  • Phone: 225-924-5655
  • Fax: 225-924-5330
Mailing address:
  • Phone: 225-810-4040
  • Fax: 225-810-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: EARL J WILDE III
Title or Position: CHAIRMAN OF THE BOARD
Credential:
Phone: 225-810-4040