Healthcare Provider Details

I. General information

NPI: 1427173954
Provider Name (Legal Business Name): NORTHSHORE COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 RIVER HIGHLANDS BLVD STE 8
COVINGTON LA
70433-8987
US

IV. Provider business mailing address

234 LAMARQUE ST
MANDEVILLE LA
70448-5931
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-2942
  • Fax: 985-231-1373
Mailing address:
  • Phone: 985-624-2942
  • Fax: 985-231-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2479
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number529
License Number StateLA

VIII. Authorized Official

Name: DR. ANDRE SAGRERA JUDICE
Title or Position: OWNER
Credential: PHD
Phone: 985-624-2942