Healthcare Provider Details

I. General information

NPI: 1295158145
Provider Name (Legal Business Name): MOMENTUM INSTITUTE OF THERAPEUTIC AND COMMUNAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S. BROAD ST.
NEW ORLEANS LA
70125
US

IV. Provider business mailing address

448 BELLEVILLE ST
NEW ORLEANS LA
70114-1115
US

V. Phone/Fax

Practice location:
  • Phone: 504-939-7996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5082
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number5082
License Number StateLA

VIII. Authorized Official

Name: JOSEPH JOHNSON
Title or Position: OWNER
Credential:
Phone: 504-939-7996