Healthcare Provider Details

I. General information

NPI: 1235442419
Provider Name (Legal Business Name): CDS ASHLEY RIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 ASHLEY RIDGE BLVD SUITE 200
SHREVEPORT LA
71106-7235
US

IV. Provider business mailing address

460 ASHLEY RIDGE BLVD SUITE 200
SHREVEPORT LA
71106-7235
US

V. Phone/Fax

Practice location:
  • Phone: 318-865-0039
  • Fax: 318-865-1986
Mailing address:
  • Phone: 318-865-0039
  • Fax: 318-865-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number316A
License Number StateLA

VIII. Authorized Official

Name: MR. ROBERT LAYNE BONVILLAIN
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: LCSW
Phone: 318-865-0039