=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861871584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANA DUET-CHAMPAGNE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2015
-----------------------------------------------------
Last Update Date | 05/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5001 HIGHWAY 190 EAST SERVICE RD SUITE D-2, OFFICE 2
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-250-7701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 549
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70447-0549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-250-7701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DANA DUET-CHAMPAGNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-250-7701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 4726
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------