Healthcare Provider Details

I. General information

NPI: 1396081097
Provider Name (Legal Business Name): CBS ACT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 FREESTATE BLVD
SHREVEPORT LA
71107-6535
US

IV. Provider business mailing address

PO BOX 7875
SHREVEPORT LA
71137-7875
US

V. Phone/Fax

Practice location:
  • Phone: 318-226-5990
  • Fax: 318-226-5994
Mailing address:
  • Phone: 318-617-5869
  • Fax: 318-226-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number10334076#LUL73
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10334076#LUL73
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10334076#LUL73
License Number StateLA

VIII. Authorized Official

Name: MS. PAMELA MICHELLE PHILLIPS
Title or Position: BUSINESS MANAGER
Credential: MBA
Phone: 318-617-5869