Healthcare Provider Details

I. General information

NPI: 1427952266
Provider Name (Legal Business Name): BLESSED KIDZ THERAPEUTIC GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 SAINT CHARLES ST
JEANERETTE LA
70544-4225
US

IV. Provider business mailing address

2023 SAINT CHARLES ST
JEANERETTE LA
70544-4225
US

V. Phone/Fax

Practice location:
  • Phone: 337-564-3504
  • Fax:
Mailing address:
  • Phone: 337-564-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: LADERICAL DELDRA WAGNER
Title or Position: EXECUTIVE DIRECTOR
Credential: JD
Phone: 337-380-3950