Provider Demographics
NPI:1427666353
Name:FRESH START PSYCHIATRIC CLINIC
Entity type:Organization
Organization Name:FRESH START PSYCHIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHIAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:CNS
Authorized Official - Phone:512-952-0295
Mailing Address - Street 1:1921 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-2716
Mailing Address - Country:US
Mailing Address - Phone:373-223-9487
Mailing Address - Fax:888-511-5650
Practice Address - Street 1:11455 FALLBROOK DR STE 201
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4267
Practice Address - Country:US
Practice Address - Phone:337-223-9487
Practice Address - Fax:888-511-5650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
11813129OtherCAQH
LA1029807Medicaid
LA600712760OtherMAGELLAN
NJNJ2611OtherBCBS#
LAMD.201514OtherMD LICENSE
LA418846OtherMHN