Healthcare Provider Details

I. General information

NPI: 1235836933
Provider Name (Legal Business Name): NORMAN CLAY RUSSELL LAC CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 PRAIRIE RD # 593
WINNSBORO LA
71295-2951
US

IV. Provider business mailing address

7060 PRAIRIE RD # 593
WINNSBORO LA
71295-2951
US

V. Phone/Fax

Practice location:
  • Phone: 318-805-4775
  • Fax: 318-435-7063
Mailing address:
  • Phone: 318-805-4775
  • Fax: 318-435-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1626
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number1626
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1626
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: