Healthcare Provider Details

I. General information

NPI: 1538236328
Provider Name (Legal Business Name): COGNITIVE DEVELOPMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 FELICIA AVE
TALLULAH LA
71282-8203
US

IV. Provider business mailing address

101 FEU FOLLET RD STE 100
LAFAYETTE LA
70508-4234
US

V. Phone/Fax

Practice location:
  • Phone: 319-574-1232
  • Fax:
Mailing address:
  • Phone: 337-234-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2203782499
License Number StateLA

VIII. Authorized Official

Name: GEMMALYN M PRYOR
Title or Position: SEASIDE HC BILLING SUPERVISOR
Credential:
Phone: 337-234-8280