Healthcare Provider Details

I. General information

NPI: 1144543489
Provider Name (Legal Business Name): WK PSYCHOLOGY SPECIALTY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS INDUSTRIAL LOOP SUITE 303
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5850
  • Fax: 318-212-5855
Mailing address:
  • Phone: 318-212-8574
  • Fax: 318-212-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-4232