Healthcare Provider Details

I. General information

NPI: 1689962722
Provider Name (Legal Business Name): WK BEHAVIORAL HEALTH MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR SUITE 340
BOSSIER CITY LA
71111-2394
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-7461
  • Fax: 318-212-7465
Mailing address:
  • Phone: 318-212-8946
  • Fax: 318-212-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-4232