Healthcare Provider Details

I. General information

NPI: 1780054577
Provider Name (Legal Business Name): SHALAURIA BEDFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 FERRAND ST SUITE 23
MONROE LA
71201-3234
US

IV. Provider business mailing address

2404 FERRAND ST SUITE 23
MONROE LA
71201-3234
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-0463
  • Fax: 318-323-0465
Mailing address:
  • Phone: 318-323-0463
  • Fax: 318-323-0465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5458
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: