Healthcare Provider Details

I. General information

NPI: 1144692773
Provider Name (Legal Business Name): LAKISIA FRYE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 09/12/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 EE WALLACE BLVD
FERRIDAY LA
71334
US

IV. Provider business mailing address

615 EE WALLACE BLVD S
FERRIDAY LA
71334-3224
US

V. Phone/Fax

Practice location:
  • Phone: 318-757-9363
  • Fax: 318-757-9364
Mailing address:
  • Phone: 318-757-9363
  • Fax: 318-757-9364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPLC9448
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: