Provider Demographics
NPI:1871089763
Name:GULF SOUTH BR - ABA, LLC
Entity type:Organization
Organization Name:GULF SOUTH BR - ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BIANCHINI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:504-780-1702
Mailing Address - Street 1:2901 N I 10 SERVICE RD E STE 300
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6137
Mailing Address - Country:US
Mailing Address - Phone:504-780-1702
Mailing Address - Fax:504-780-1705
Practice Address - Street 1:9063 SIEGEN LN STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:504-780-1702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty