Healthcare Provider Details

I. General information

NPI: 1831739820
Provider Name (Legal Business Name): PSYCHOLOGY ASSOCIATES OF N.W. LOUISIANA, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2020
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KIMBER FULLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-425-2000