Healthcare Provider Details

I. General information

NPI: 1043753890
Provider Name (Legal Business Name): VICKIE MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY PL STE 135
SHREVEPORT LA
71118-2528
US

IV. Provider business mailing address

9094 SUMMER TREE CIR
GREENWOOD LA
71033-3051
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax:
Mailing address:
  • Phone: 601-410-1627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC9410
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC9410
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: