1477925469 NPI number — MS. MIA DESHAWN WHITESIDE LCSW

Table of content: MS. MIA DESHAWN WHITESIDE LCSW (NPI 1477925469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477925469 NPI number — MS. MIA DESHAWN WHITESIDE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITESIDE
Provider First Name:
MIA
Provider Middle Name:
DESHAWN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITESIDE
Provider Other First Name:
MIA
Provider Other Middle Name:
DESHAWN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477925469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 EAST STONER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-221-8411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 E STONER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-221-8411
Provider Business Practice Location Address Fax Number:
915-742-4890
Provider Enumeration Date:
10/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  62608 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 62608 . This is a "ASSOCIATES OF SOCIAL WORK BOARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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