=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417668146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 318 THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2022
-----------------------------------------------------
Last Update Date | 12/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3004 KNIGHT ST BLDG 6
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71105-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-207-1542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2838 LONG LAKE DR
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-8422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-207-1542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | CRISTINA HAYES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 214-207-1542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------