=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578822177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOYS AND GIRLS VILLAGES FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2012
-----------------------------------------------------
Last Update Date | 05/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7378 HIGHWAY 90 E
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70615-4803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-436-7553
-----------------------------------------------------
Fax | 337-436-8291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7378 HIGHWAY 90 E
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70615-4803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-436-7553
-----------------------------------------------------
Fax | 337-436-8291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MAYANCE JOSEPH MATHIEU, JR.
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 337-436-7553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 8998
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------