Healthcare Provider Details

I. General information

NPI: 1407249766
Provider Name (Legal Business Name): RIVERPARK COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT ST STE 2134
VIDALIA LA
71373-2836
US

IV. Provider business mailing address

107 FRONT ST STE 2134
VIDALIA LA
71373-2836
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2212
  • Fax:
Mailing address:
  • Phone: 318-336-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12091
License Number StateLA

VIII. Authorized Official

Name: JOHN FAIRBANKS
Title or Position: OWNER
Credential: MD
Phone: 318-336-2212