Healthcare Provider Details

I. General information

NPI: 1396285581
Provider Name (Legal Business Name): CENTER FOR INTEGRATED BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10473 OLD HAMMOND HWY
BATON ROUGE LA
70816-8264
US

IV. Provider business mailing address

10473 OLD HAMMOND HWY
BATON ROUGE LA
70816-8264
US

V. Phone/Fax

Practice location:
  • Phone: 225-924-1910
  • Fax: 225-924-1988
Mailing address:
  • Phone: 225-924-1910
  • Fax: 225-924-1988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. RANDAL A GOMEZ
Title or Position: CEO
Credential:
Phone: 225-933-9000