=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376780783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN D. OSBORN, LCSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2009
-----------------------------------------------------
Last Update Date | 01/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5001 HIGHWAY 190 EAST SERVICE RD STE D1
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-4956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-373-4818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 404
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70447-0404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. BRIAN D OSBORN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 985-373-4818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 251S00000X
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------