Healthcare Provider Details

I. General information

NPI: 1548936925
Provider Name (Legal Business Name): LA PAZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 S VIENNA ST
RUSTON LA
71270-6428
US

IV. Provider business mailing address

1406 S VIENNA ST
RUSTON LA
71270-6428
US

V. Phone/Fax

Practice location:
  • Phone: 318-224-9200
  • Fax: 318-224-9201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: LAKYSHA STARKS- SAMPSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 318-210-2996