Healthcare Provider Details

I. General information

NPI: 1164935649
Provider Name (Legal Business Name): SHAREE NICOLE LIGHT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax:
Mailing address:
  • Phone: 318-626-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1629
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1629
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: