MEDICARE: CENLA WELLNESS CENTER, 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	3568	LA
2	101YM0800X	Mental Health Counselor	3568	LA
3	101YP2500X	Professional Counselor	3568	LA

General Provider Information

NPI Number	:	1275771354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENLA WELLNESS CENTER, LLC.

Provider Business Mailing Address
First Line	:	3818A BAYOU RAPIDES RD
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-3655
Country	:	US
Telephone Number	:	314-449-8571
Fax Number	:	318-449-8506

Provider Business Practice Location Address
First Line	:	3818A BAYOU RAPIDES RD
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-3655
Country	:	US
Telephone Number	:	314-449-8571
Fax Number	:	318-449-8506

Authorized Official
Title or Position	:	OWNER
Name	:	DONNA SWISHER
Credential	:	LPC
Telephone Number	:	318-449-8571

Provider Enumeration Date	:	01/28/2009
Last Update Date	:	01/28/2009

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