Provider Demographics
NPI:1972965556
Name:MIND REHABILITATION & RESOURCE CENTER
Entity type:Organization
Organization Name:MIND REHABILITATION & RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:318-828-1455
Mailing Address - Street 1:1259 FULLILOVE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-3340
Mailing Address - Country:US
Mailing Address - Phone:318-200-7859
Mailing Address - Fax:
Practice Address - Street 1:1259 FULLILOVE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3340
Practice Address - Country:US
Practice Address - Phone:318-200-7859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1851688105Medicaid