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General NPI Number Information
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NPI Number | 1730908104
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Entity Type | Organization
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Legal Business Name | BEYOND THE BRICK WALL
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Dates
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Enumeration Date | 10/03/2024
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | 820 JORDAN ST STE 550
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City | SHREVEPORT
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State | LA
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Zip | 71101-4526
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Country | US
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Telephone | 318-734-9022
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Fax |
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Provider Business Mailing Address
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Address Line | 820 JORDAN ST STE 550
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City | SHREVEPORT
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State | LA
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Zip | 71101-4526
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Country | US
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Telephone | 318-734-9022
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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 | ROBERT NOWLIN GARDNER
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Credential |
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Telephone | 318-734-8492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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