Provider Demographics
NPI:1386277283
Name:BEACON BEHAVIORAL HOSPITAL LLC
Entity type:Organization
Organization Name:BEACON BEHAVIORAL HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4040
Mailing Address - Street 1:4601 BLUEBONNET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9656
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:2471 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LUTCHER
Practice Address - State:LA
Practice Address - Zip Code:70071-5413
Practice Address - Country:US
Practice Address - Phone:225-258-6112
Practice Address - Fax:225-258-6111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2184164Medicaid
194102OtherMEDICARE