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General NPI Number Information
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NPI Number | 1174991186
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Entity Type | Organization
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Legal Business Name | AGAPE CENTER FOR TROUBLED YOUTH
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | 2013 MACARTHUR DR BLDG 2
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City | ALEXANDRIA
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State | LA
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Zip | 71301-3720
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Country | US
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Telephone | 318-787-1114
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Fax | 318-487-6287
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Provider Business Mailing Address
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Address Line | 610 WEBSTER ST
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City | PINEVILLE
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State | LA
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Zip | 71360-6948
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Country | US
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Telephone | 318-787-1114
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Fax | 318-487-6287
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | BARBARA ANN WATSON
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Credential | LCSW
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Telephone | 318-787-1114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 6319
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6319
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License Number State | LA
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