Provider Demographics
NPI:1053770685
Name:IMPACT BEHAVIORAL
Entity type:Organization
Organization Name:IMPACT BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MIESHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:504-394-1774
Mailing Address - Street 1:4700 WICHERS DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3041
Mailing Address - Country:US
Mailing Address - Phone:504-407-0709
Mailing Address - Fax:504-333-6252
Practice Address - Street 1:4700 WICHERS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-407-0709
Practice Address - Fax:504-333-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health