Provider Demographics
NPI:1609194356
Name:WK CENTER FOR PSYCHIATRIC SUPPORT
Entity type:Organization
Organization Name:WK CENTER FOR PSYCHIATRIC SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:1111 LINE AVE 3RD FLOOR TOWER 2
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3981
Mailing Address - Country:US
Mailing Address - Phone:318-716-4610
Mailing Address - Fax:318-716-4690
Practice Address - Street 1:1111 LINE AVE 3RD FLOOR TOWER 2
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3981
Practice Address - Country:US
Practice Address - Phone:318-716-4610
Practice Address - Fax:318-716-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DP83Medicare PIN