MEDICARE: MIND, BODY & SOUL OF NEW ORLEANS, INC.

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	1167	LA
2	101YM0800X	Mental Health Counselor	1167	LA
3	101YS0200X	School Counselor	1167	LA
4	104100000X	Social Worker	1167	LA
5	1041C0700X	Clinical Social Worker	1167	LA
6	101Y00000X	Counselor	1167	LA

General Provider Information

NPI Number	:	1740443399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND, BODY & SOUL OF NEW ORLEANS, INC.

Provider Business Mailing Address
First Line	:	57 5TH ST
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70053-4744
Country	:	US
Telephone Number	:	504-331-5788
Fax Number	:

Provider Business Practice Location Address
First Line	:	57 5TH ST
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70053-4744
Country	:	US
Telephone Number	:	504-331-5788
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ALBERT BRYAN
Credential	:	LAC
Telephone Number	:	504-331-5788

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	07/03/2008

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