=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154855591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN ARMS BEHAVIORAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 W CORNERVIEW ST
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-4105
-----------------------------------------------------
Fax | 866-234-8190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 359
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70707-0359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-647-4105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEMARCUS D PATTERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-647-4105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2203783205
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------