Healthcare Provider Details

I. General information

NPI: 1124643606
Provider Name (Legal Business Name): EXCEPTIONAL WELLNESS OF LOUISIANA INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 MILAM ST
SHREVEPORT LA
71101-5353
US

IV. Provider business mailing address

2440 TEXAS PKWY STE 335
MISSOURI CITY TX
77489-4098
US

V. Phone/Fax

Practice location:
  • Phone: 318-383-1607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LATONIA KENT
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-383-1607