Organization
MIND REHABILITATION & RESOURCE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TONYA M RILEY LPC-S (CLINICAL SUPERVISOR)
(318) 828-1455
Entity
Organization
Contact information
Practice address
1259 FULLILOVE DR, BOSSIER CITY, LA 71112-3340
(318) 200-7859
Mailing address
1259 FULLILOVE DR, BOSSIER CITY, LA 71112-3340
(318) 200-7859
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1851688105
—
LA
Enumeration date
03/23/2016
Last updated
03/23/2016
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