Provider Demographics
NPI:1598508582
Name:A REFUGE OF LA
Entity type:Organization
Organization Name:A REFUGE OF LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MILEY
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:225-315-2415
Mailing Address - Street 1:103 BUSINESS PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-7825
Mailing Address - Country:US
Mailing Address - Phone:225-315-2415
Mailing Address - Fax:225-664-4406
Practice Address - Street 1:103 BUSINESS PARK DR STE B
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-7825
Practice Address - Country:US
Practice Address - Phone:225-315-2415
Practice Address - Fax:225-664-4406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A REFUGE OF LA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1518013499OtherNPI