Healthcare Provider Details

I. General information

NPI: 1730446410
Provider Name (Legal Business Name): FAMILY PSYCHOLOGY AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LINE AVE SUITE 305
SHREVEPORT LA
71101-4621
US

IV. Provider business mailing address

1513 LINE AVE SUITE 305
SHREVEPORT LA
71101-4621
US

V. Phone/Fax

Practice location:
  • Phone: 318-865-7500
  • Fax: 318-868-2035
Mailing address:
  • Phone: 318-865-7500
  • Fax: 318-868-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE KQ MCCORMICK
Title or Position: MEDICAL PSYCHOLOGIST/OWNER
Credential: PH.D.
Phone: 318-865-7500