Healthcare Provider Details

I. General information

NPI: 1104459064
Provider Name (Legal Business Name): SPRINGLAKE BEHAVIORAL HEALTH BUNKIE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 12/24/2020
Certification Date: 12/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 I 49 N SERVICE RD STE 11
OPELOUSAS LA
70570-0780
US

IV. Provider business mailing address

4601 BLUEBONNET BLVD STE B
BATON ROUGE LA
70809-9656
US

V. Phone/Fax

Practice location:
  • Phone: 337-678-3611
  • Fax: 337-678-3599
Mailing address:
  • Phone: 225-810-4040
  • Fax: 225-810-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP SEAN WENDELL
Title or Position: CEO
Credential:
Phone: 337-678-3611