Healthcare Provider Details

I. General information

NPI: 1801518782
Provider Name (Legal Business Name): NATISHA MARIE PURVIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 MAGGIO RD
BENTON LA
71006-0017
US

IV. Provider business mailing address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

V. Phone/Fax

Practice location:
  • Phone: 479-462-9319
  • Fax:
Mailing address:
  • Phone: 318-861-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4182
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: