Healthcare Provider Details

I. General information

NPI: 1740443399
Provider Name (Legal Business Name): MIND, BODY & SOUL OF NEW ORLEANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 5TH ST
GRETNA LA
70053-4744
US

IV. Provider business mailing address

57 5TH ST
GRETNA LA
70053-4744
US

V. Phone/Fax

Practice location:
  • Phone: 504-331-5788
  • Fax:
Mailing address:
  • Phone: 504-331-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1167
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1167
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1167
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1167
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1167
License Number StateLA
# 6
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1167
License Number StateLA

VIII. Authorized Official

Name: ALBERT BRYAN
Title or Position: CEO
Credential: LAC
Phone: 504-331-5788