MEDICARE: RAY OF LIGHT BEHAVIORAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	L-146	LA
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1063875284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAY OF LIGHT BEHAVIORAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	4104 RAINER ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71107-7744
Country	:	US
Telephone Number	:	318-655-3006
Fax Number	:

Provider Business Practice Location Address
First Line	:	4104 RAINER ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71107-7744
Country	:	US
Telephone Number	:	318-655-3006
Fax Number	:

Authorized Official
Title or Position	:	BOARD CERTIFIED BEHAVIOR ANALYST
Name	:	ERIKA RICHTER
Credential	:	MA, BCBA
Telephone Number	:	318-655-3006

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	05/09/2018

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