Healthcare Provider Details

I. General information

NPI: 1790283638
Provider Name (Legal Business Name): BROOKYS HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 JONES ST
SHREVEPORT LA
71101-4021
US

IV. Provider business mailing address

217 JONES ST
SHREVEPORT LA
71101-4021
US

V. Phone/Fax

Practice location:
  • Phone: 318-423-1367
  • Fax: 318-216-3380
Mailing address:
  • Phone: 318-423-1367
  • Fax: 318-216-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number101YM0800X
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number103TH0004X
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101Y00000X
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101YM0800X
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101Y00000X
License Number StateLA

VIII. Authorized Official

Name: DIANE WILLIAMS
Title or Position: OWNER
Credential:
Phone: 318-423-1367