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General NPI Number Information
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NPI Number | 1457713224
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Entity Type | Organization
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Legal Business Name | BAYOU MENTAL HEALTH OF ALEXANDRIA AND DERIDDER
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Dates
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Enumeration Date | 03/22/2016
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Last Update Date | 03/22/2016
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Provider Practice Location Address
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Address Line | 1605 MURRAY ST SUITE 104
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City | ALEXANDRIA
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State | LA
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Zip | 71301-6890
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Country | US
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Telephone | 318-623-5839
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 12726
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City | ALEXANDRIA
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State | LA
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Zip | 71315-2726
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | KNAKITA BAILEY
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Credential |
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Telephone | 318-623-5839
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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 | MD201241
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License Number State | LA
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