Healthcare Provider Details

I. General information

NPI: 1477850667
Provider Name (Legal Business Name): THOMANDRA SHAVAUN SAM PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 PERKINS RD
BATON ROUGE LA
70808-4124
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-330-0497
  • Fax: 225-330-0498
Mailing address:
  • Phone: 225-330-0497
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1331
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: