Healthcare Provider Details

I. General information

NPI: 1801289020
Provider Name (Legal Business Name): BEHAVIORAL SPECIALISTS OF LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 OLIVE ST
SHREVEPORT LA
71104-2103
US

IV. Provider business mailing address

925 OLIVE STREET
SHREVEPORT LA
71104
US

V. Phone/Fax

Practice location:
  • Phone: 318-300-3560
  • Fax: 318-300-3561
Mailing address:
  • Phone: 318-300-3560
  • Fax: 318-300-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateLA

VIII. Authorized Official

Name: AMY C BAMBURG
Title or Position: COO/AGENT
Credential:
Phone: 318-442-4498