Healthcare Provider Details

I. General information

NPI: 1427137074
Provider Name (Legal Business Name): REHABILITATION SERVICES OF NORTHWEST LOUISIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 YOUREE DR
SHREVEPORT LA
71101-5117
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-0804
  • Fax: 318-425-9030
Mailing address:
  • Phone: 318-746-0420
  • Fax: 318-626-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1151254
License Number StateLA

VIII. Authorized Official

Name: MATTHEW ST. AMANT
Title or Position: OWNER/OPERATOR
Credential:
Phone: 318-675-0804