Healthcare Provider Details

I. General information

NPI: 1902334931
Provider Name (Legal Business Name): REGINALD SHAFFER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13621 KENNER AVE APT C
BATON ROUGE LA
70810
US

IV. Provider business mailing address

13621 KENNER AVE APT C
BATON ROUGE LA
70810-9102
US

V. Phone/Fax

Practice location:
  • Phone: 225-571-4184
  • Fax:
Mailing address:
  • Phone: 225-571-4184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: