Healthcare Provider Details

I. General information

NPI: 1538121611
Provider Name (Legal Business Name): MEDA ANN KILLGORE L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 KILGORE RD RUSTON
RUSTON LA
71270-7084
US

IV. Provider business mailing address

200 JEFFERSON OAKS DR RUSTON
RUSTON LA
71270-7083
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-1418
  • Fax: 318-255-1189
Mailing address:
  • Phone: 318-255-5145
  • Fax: 318-255-1189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4345
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: