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General NPI Number Information
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NPI Number | 1902591514
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Entity Type | Organization
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Legal Business Name | M & M THERAPEUTIC GROUP HOME, LLP
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Dates
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Enumeration Date | 04/10/2023
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Last Update Date | 04/10/2023
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Provider Practice Location Address
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Address Line | 617 TENNESSEE STREET
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City | DELHI
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State | LA
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Zip | 71232
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Country | US
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Telephone | 318-538-0600
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Fax | 318-538-0602
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Provider Business Mailing Address
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Address Line | 617 TENNESSEE STREET
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City | DELHI
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State | LA
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Zip | 71232
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Country | US
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Telephone | 318-538-0600
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Fax | 318-538-0602
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Authorized Official
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Title or Position | LPC, CEO
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Name | FELECIA DAVIS MODICUE
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Credential | CLINICAL DIRECTOR
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Telephone | 318-680-8414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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