Healthcare Provider Details

I. General information

NPI: 1043719875
Provider Name (Legal Business Name): COMMUNITY BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24038 HIGHWAY 371
SAREPTA LA
71071-3206
US

IV. Provider business mailing address

24038 HIGHWAY 371
SAREPTA LA
71071-3206
US

V. Phone/Fax

Practice location:
  • Phone: 318-847-0140
  • Fax:
Mailing address:
  • Phone: 318-847-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LA'BREDA L GRAY
Title or Position: OWNER/CEO
Credential: MBA
Phone: 318-205-8044