1205031044 NPI number — LOUISIANA YOUTH ENHANCED SERVICES

Table of content: (NPI 1205031044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205031044 NPI number — LOUISIANA YOUTH ENHANCED SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISIANA YOUTH ENHANCED SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205031044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 STATE ST
Provider Second Line Business Mailing Address:
COTTAGE #4
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70118-5735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-896-2636
Provider Business Mailing Address Fax Number:
504-896-2668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 VERSAILLES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70125-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-866-7576
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIPOLL
Authorized Official First Name:
KAWANA
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE CLINICAL DIRECTOR
Authorized Official Telephone Number:
504-896-2636

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  MD.09289R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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