# DNP-OUTPATIENT

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** SOUTHEAST LOUISIANA STATE HOSPITAL
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1235366204
- **Legal business name:** SOUTHEAST LOUISIANA STATE HOSPITAL
- **Authorized official:** PATRICIA GONZALES (C.E.O.)
- **Authorized official phone:** (985) 626-6300

## Contact information

- **Practice address:** 23515 HWY 190, MANDEVILLE, LA 70448
- **Practice address phone:** (985) 626-6300
- **Practice address fax:** (985) 626-6557
- **Mailing address:** PO BOX 3850, MANDEVILLE, LA 70470-3850
- **Mailing address phone:** (985) 626-6300
- **Mailing address fax:** (985) 626-6557

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2084P0005X | Neurodevelopmental Disabilities Physician | — | NULL | Yes |
| 2084P0005X | Neurodevelopmental Disabilities Physician | — | — | Yes |

## Other

- **Enumeration date:** 06/17/2009
- **Last updated:** 06/17/2009