Healthcare Provider Details

I. General information

NPI: 1992151542
Provider Name (Legal Business Name): MARY LOWERY NORDBERG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 MISSOURI AVE
SHREVEPORT LA
71109-4327
US

IV. Provider business mailing address

802 ERIE ST
SHREVEPORT LA
71106-1506
US

V. Phone/Fax

Practice location:
  • Phone: 318-621-8820
  • Fax: 318-212-4189
Mailing address:
  • Phone: 318-393-4089
  • Fax: 318-681-4657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: