Provider Demographics
NPI:1063569648
Name:INSTNEUROPSYCHADVANCED HC
Entity type:Organization
Organization Name:INSTNEUROPSYCHADVANCED HC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTCEO
Authorized Official - Prefix:
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-477-7091
Mailing Address - Street 1:2829 4TH AVE
Mailing Address - Street 2:150
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7887
Mailing Address - Country:US
Mailing Address - Phone:337-477-7091
Mailing Address - Fax:337-474-4552
Practice Address - Street 1:2829 4TH AVE
Practice Address - Street 2:150
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7887
Practice Address - Country:US
Practice Address - Phone:337-477-7091
Practice Address - Fax:337-474-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAADC6247251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551228Medicaid