Healthcare Provider Details

I. General information

NPI: 1285095547
Provider Name (Legal Business Name): DEVIN O'NEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 N MARKET ST STE. A
SHREVEPORT LA
71107
US

IV. Provider business mailing address

4609 N MARKET ST STE. A
SHREVEPORT LA
71107-2900
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-5462
  • Fax: 318-626-5562
Mailing address:
  • Phone: 318-626-5462
  • Fax: 318-626-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health 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: