Healthcare Provider Details

I. General information

NPI: 1598805624
Provider Name (Legal Business Name): WINNSBORO-COLUMBIA MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 LANDIS ST SUITE-B
WINNSBORO LA
71295-2642
US

IV. Provider business mailing address

1301 LANDIS ST SUITE - B
WINNSBORO LA
71295-2642
US

V. Phone/Fax

Practice location:
  • Phone: 318-435-2146
  • Fax: 318-435-2134
Mailing address:
  • Phone: 318-435-2146
  • Fax: 318-435-2134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN086019
License Number StateLA

VIII. Authorized Official

Name: MR. GREGORY L. WRENN
Title or Position: REGISTERED NURSE III
Credential:
Phone: 318-435-2146