Healthcare Provider Details

I. General information

NPI: 1730843012
Provider Name (Legal Business Name): SELF-ISH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 RYAN ST STE 134
LAKE CHARLES LA
70605-4514
US

IV. Provider business mailing address

4310 RYAN ST STE 134
LAKE CHARLES LA
70605-4514
US

V. Phone/Fax

Practice location:
  • Phone: 337-873-1203
  • Fax:
Mailing address:
  • Phone: 337-873-1203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ROYCE CHARLES
Title or Position: OWNER
Credential:
Phone: 337-873-1203