MEDICARE: SHONTELL BUFFINGTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	12396	LA

General Provider Information

NPI Number	:	1417474057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONTELL BUFFINGTON LCSW

Provider Business Mailing Address
First Line	:	PO BOX 64594
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70896-4594
Country	:	US
Telephone Number	:	225-366-8766
Fax Number	:	225-208-1800

Provider Business Practice Location Address
First Line	:	3029 S SHERWOOD FOREST BLVD STE 205
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2276
Country	:	US
Telephone Number	:	225-366-8766
Fax Number	:	225-208-1800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	11/01/2021

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