Healthcare Provider Details

I. General information

NPI: 1477732188
Provider Name (Legal Business Name): RONALD A GOEBEL & MARK P VIGEN PTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

IV. Provider business mailing address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-2000
  • Fax: 318-424-2601
Mailing address:
  • Phone: 318-425-2000
  • Fax: 318-424-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RONALD A. GOEBEL
Title or Position: PARTNER
Credential: PH.D.
Phone: 318-425-2000