Healthcare Provider Details

I. General information

NPI: 1033541230
Provider Name (Legal Business Name): NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 WHITE ST
RUSTON LA
71270-5960
US

IV. Provider business mailing address

901 WHITE ST
RUSTON LA
71270-5960
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-4125
  • Fax: 318-251-5000
Mailing address:
  • Phone: 318-251-4125
  • Fax: 318-251-5000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1710342
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer
# 2
Identifier2203785977
Identifier TypeOTHER
Identifier StateLA
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name: OCTAVIA GREEN
Title or Position: ADMINISTRATIVE PROGRAM SPECIALIST B
Credential:
Phone: 318-362-3270