Healthcare Provider Details

I. General information

NPI: 1578574471
Provider Name (Legal Business Name): CYPRESS GROVE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PINE ST
MONROE LA
71201-6228
US

IV. Provider business mailing address

550 MAIN STREET SUITE 250, CONTRACTING/CREDENTIALING
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 318-699-8819
  • Fax:
Mailing address:
  • Phone: 612-326-7575
  • Fax: 612-454-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number StateLA

VIII. Authorized Official

Name: JAMES SMITH
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 612-326-7575