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General NPI Number Information
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NPI Number | 1083073217
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Entity Type | Organization
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Legal Business Name | MIND REHABILITATION & RESOURCE CENTER
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Dates
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Enumeration Date | 02/16/2016
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Last Update Date | 02/16/2016
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Provider Practice Location Address
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Address Line | 1513 LINE AVE STE 135
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City | SHREVEPORT
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State | LA
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Zip | 71101-4621
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Country | US
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Telephone | 318-828-1455
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Fax |
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Provider Business Mailing Address
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Address Line | 2923 OAK FOREST LN
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City | SHREVEPORT
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State | LA
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Zip | 71107-5802
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Country | US
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Telephone | 318-780-2828
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH PROFESSIONAL
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Name | MRS. KAMIQUE MICHELLE JOHNSON
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Credential |
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Telephone | 318-780-2828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 19320000X/101YM0800X
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License Number State | LA
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