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General NPI Number Information
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NPI Number | 1013466051
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Entity Type | Organization
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Legal Business Name | COGNITIVE DEVELOPMENT CENTER
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Dates
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Enumeration Date | 10/03/2016
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Last Update Date | 10/03/2016
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Provider Practice Location Address
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Address Line | 316 WOODALE DR APT 11
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City | MONROE
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State | LA
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Zip | 71203-2712
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Country | US
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Telephone | 318-600-6045
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Fax |
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Provider Business Mailing Address
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Address Line | 316 WOODALE DR APT 11
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City | MONROE
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State | LA
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Zip | 71203-2712
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Country | US
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Telephone | 318-600-6045
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Fax |
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Authorized Official
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Title or Position | MHP
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Name | CHELLCY JACKSON
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Credential | M.S.
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Telephone | 318-418-0329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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