=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528755428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELAIRE YOUTH HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2023
-----------------------------------------------------
Last Update Date | 07/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6530 BURKE ST
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71108-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-470-6881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6530 BURKE ST
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71108-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JARICA JOHNSON
-----------------------------------------------------
Credential | MHA
-----------------------------------------------------
Telephone | 318-693-0059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------