=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437554904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COGNITIVE DEVELOPMENT CTR PERSONAL CARE SERVIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2014
-----------------------------------------------------
Last Update Date | 10/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1811 ROSELAWN AVE
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-5433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-651-8080
-----------------------------------------------------
Fax | 318-651-8081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7563
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71211-7563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-651-8080
-----------------------------------------------------
Fax | 318-651-8081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. ADRIAN FISHER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 318-651-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 10839
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------