Healthcare Provider Details

I. General information

NPI: 1710869003
Provider Name (Legal Business Name): LASHAWN BENITA HARLEY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 RIVERWOOD LOOP APT C
BOSSIER CITY LA
71111-7948
US

IV. Provider business mailing address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

V. Phone/Fax

Practice location:
  • Phone: 318-465-6574
  • Fax:
Mailing address:
  • Phone: 318-861-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC10783
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC10783
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: