1790237048 NPI number — LASHEKA SHINE LCSW-BACS

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 1790237048 NPI number — LASHEKA SHINE LCSW-BACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHINE
Provider First Name:
LASHEKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW-BACS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DREW-SMITH
Provider Other First Name:
LASHEKA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW-BACS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790237048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3018 OLD MINDEN RD STE 1111A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71112-2476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-751-6687
Provider Business Mailing Address Fax Number:
318-800-4448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3018 OLD MINDEN RD STE 1111A
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:
71112-2476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-751-6687
Provider Business Practice Location Address Fax Number:
318-751-6687
Provider Enumeration Date:
11/02/2016

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:  0904013799 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 12448 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 852058844 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 852058844 . This is a "PRIVATE INSURANCE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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