Provider Demographics
NPI:1023484706
Name:IMPACT BEHAVIOR HEALTH SERVICES LLC.
Entity type:Organization
Organization Name:IMPACT BEHAVIOR HEALTH SERVICES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:504-407-0709
Mailing Address - Street 1:4700 WICHER DR.
Mailing Address - Street 2:4700 WICHERS DR SUITE 205B
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-407-0709
Mailing Address - Fax:504-333-6252
Practice Address - Street 1:4700 WICHERS DR
Practice Address - Street 2:MARRERO SUITE 205B
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-407-0907
Practice Address - Fax:504-333-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health