Healthcare Provider Details

I. General information

NPI: 1205354974
Provider Name (Legal Business Name): MISS-LOU ADDICTION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 07/21/2022
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ALEXANDER ST
JONESBORO LA
71251-2001
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 903
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-0270
  • Fax: 888-981-2815
Mailing address:
  • Phone: 318-459-6795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1112895
License Number StateMS

VIII. Authorized Official

Name: MONA LISA PETERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, BSW
Phone: 601-442-0270