Healthcare Provider Details

I. General information

NPI: 1730660176
Provider Name (Legal Business Name): EPIPHANY HEALTHCARE SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 C M FAGAN DR BLDG A SUITE 6A
HAMMOND LA
70403
US

IV. Provider business mailing address

906 C M FAGAN DR BLDG A SUITE 6A
HAMMOND LA
70403-6056
US

V. Phone/Fax

Practice location:
  • Phone: 985-956-7370
  • Fax: 985-956-7371
Mailing address:
  • Phone: 985-956-7370
  • Fax: 985-956-7371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DICKSON OSANU
Title or Position: CEO
Credential:
Phone: 404-226-9131