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General NPI Number Information
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NPI Number | 1215349816
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Entity Type | Organization
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Legal Business Name | LASTING IMPRESSION THERAPEUTIC COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 05/30/2014
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Last Update Date | 03/22/2018
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Provider Practice Location Address
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Address Line | 2805 5TH AVE
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7913
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Country | US
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Telephone | 337-429-5672
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Fax | 337-429-5657
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Provider Business Mailing Address
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Address Line | 2805 5TH AVE
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7913
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Country | US
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Telephone | 337-377-8225
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Fax |
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Authorized Official
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Title or Position | FOUNDER/CEO
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Name | MRS. NATALIA BUTLER
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Credential | CART, DS
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Telephone | 337-377-8225
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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 | 2203783804
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License Number State | LA
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