Healthcare Provider Details

I. General information

NPI: 1518389626
Provider Name (Legal Business Name): MICHAEL MUMME MCSHAN JR. M.ED., LPC, LAC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WILKINSON ST
MANDEVILLE LA
70448-3533
US

IV. Provider business mailing address

102E COVINGTON MEADOW CIR STE E
COVINGTON LA
70433-6606
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-4450
  • Fax:
Mailing address:
  • Phone: 985-237-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number302349
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1492
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5377
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: