Provider Demographics
NPI:1124772009
Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Entity type:Organization
Organization Name:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE PROGRAM SPECIALIST B
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-362-3270
Mailing Address - Street 1:4800 S GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6412
Mailing Address - Country:US
Mailing Address - Phone:318-362-3339
Mailing Address - Fax:318-362-3336
Practice Address - Street 1:4800 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6412
Practice Address - Country:US
Practice Address - Phone:318-362-3339
Practice Address - Fax:318-362-3336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST DELTA HUMAN SERVICES AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710237Medicaid