1356804694 NPI number — SHREVEPORT BOSSIER LA COUNSELING SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356804694 NPI number — SHREVEPORT BOSSIER LA COUNSELING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHREVEPORT BOSSIER LA COUNSELING SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356804694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7109 PINE OAK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71033-3377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-613-6912
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2285 BENTON RD STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-7933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-613-6912
Provider Business Practice Location Address Fax Number:
318-666-2294
Provider Enumeration Date:
04/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BLEAKLEY
Authorized Official First Name:
ADRIENNE
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
LICENSED PROFESSION COUNSELOR
Authorized Official Telephone Number:
318-613-6912

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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