Healthcare Provider Details

I. General information

NPI: 1548620552
Provider Name (Legal Business Name): MADE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 6TH ST APT B
VIOLET LA
70092-3083
US

IV. Provider business mailing address

PO BOX 224
VIOLET LA
70092-0224
US

V. Phone/Fax

Practice location:
  • Phone: 504-221-5003
  • Fax:
Mailing address:
  • Phone: 504-221-5003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateLA

VIII. Authorized Official

Name: ASHLAY A DOUGLAS
Title or Position: OWNER/CEO
Credential: AA, AAS, BA, MSW
Phone: 504-221-5003