=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407561533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOURNEY ON THE BAYOU
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2023
-----------------------------------------------------
Last Update Date | 01/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38250 SUSAN CT
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-6079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-485-9985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38250 SUSAN CT
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-6079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-485-9985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR/COUNSELOR
-----------------------------------------------------
Name | MS. ALFREDA M FULTON
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 225-485-9985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------