Healthcare Provider Details

I. General information

NPI: 1891421590
Provider Name (Legal Business Name): LACY LONG BUCKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FAIRFIELD AVE
SHREVEPORT LA
71104-2099
US

IV. Provider business mailing address

2000 FAIRFIELD AVE
SHREVEPORT LA
71104-2099
US

V. Phone/Fax

Practice location:
  • Phone: 318-222-8511
  • Fax: 318-425-9670
Mailing address:
  • Phone: 318-222-8511
  • Fax: 318-425-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: