MEDICARE: LOUISIANA ADDICTION 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	576	LA

General Provider Information

NPI Number	:	1992042634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA ADDICTION SERVICES, LLC

Provider Business Mailing Address
First Line	:	1295 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-243-5573
Fax Number	:	225-243-6029

Provider Business Practice Location Address
First Line	:	1295 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-243-5573
Fax Number	:	225-243-6029

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID P DICKSON
Credential	:	MA LAC CCS SAP
Telephone Number	:	225-243-5573

Provider Enumeration Date	:	01/15/2013
Last Update Date	:	01/15/2013

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