MEDICARE: NICOLETTE BLOOD BS, MPH

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	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962917898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLETTE BLOOD BS, MPH

Provider Business Mailing Address
First Line	:	3007 KNIGHT ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2538
Country	:	US
Telephone Number	:	318-221-8244
Fax Number	:	318-861-2162

Provider Business Practice Location Address
First Line	:	3007 KNIGHT ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2538
Country	:	US
Telephone Number	:	318-221-8244
Fax Number	:	318-861-2162

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

Provider Enumeration Date	:	12/14/2017
Last Update Date	:	09/27/2018

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