Provider Demographics
NPI:1174991186
Name:AGAPE CENTER FOR TROUBLED YOUTH
Entity type:Organization
Organization Name:AGAPE CENTER FOR TROUBLED YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-787-1114
Mailing Address - Street 1:610 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6948
Mailing Address - Country:US
Mailing Address - Phone:318-787-1114
Mailing Address - Fax:318-487-6287
Practice Address - Street 1:2013 MACARTHUR DR
Practice Address - Street 2:BLDG 2
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3720
Practice Address - Country:US
Practice Address - Phone:318-787-1114
Practice Address - Fax:318-487-6287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6319302F00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty