Healthcare Provider Details

I. General information

NPI: 1720111230
Provider Name (Legal Business Name): EQUIPOISE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32900 PITCHER RD
SPRINGFIELD LA
70462-8334
US

IV. Provider business mailing address

32900 PITCHER RD
SPRINGFIELD LA
70462-8334
US

V. Phone/Fax

Practice location:
  • Phone: 225-294-5955
  • Fax: 225-294-5955
Mailing address:
  • Phone: 225-294-5955
  • Fax: 225-294-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1907
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL012746
License Number StateLA

VIII. Authorized Official

Name: PAULA HOTARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 225-294-5955