=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578905386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST DELTA HUMAN SERVICES AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2013
-----------------------------------------------------
Last Update Date | 10/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 LANDIS ST STE B
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71295-2642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-435-2146
-----------------------------------------------------
Fax | 318-435-2134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 LANDIS ST STE B
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71295-2642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-435-2146
-----------------------------------------------------
Fax | 318-435-2134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE PROGRAM SPECIALIST B
-----------------------------------------------------
Name | OCTAVIA GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-362-3270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2203782560-A
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------