Provider Demographics
NPI:1730908104
Name:BEYOND THE BRICK WALL
Entity type:Organization
Organization Name:BEYOND THE BRICK WALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NOWLIN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-734-8492
Mailing Address - Street 1:820 JORDAN ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4526
Mailing Address - Country:US
Mailing Address - Phone:318-734-9022
Mailing Address - Fax:
Practice Address - Street 1:820 JORDAN ST STE 550
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4526
Practice Address - Country:US
Practice Address - Phone:318-734-9022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548901044OtherNPI NUMBER