Healthcare Provider Details

I. General information

NPI: 1376087320
Provider Name (Legal Business Name): NETOSHA MACDONALD M. ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2016
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LINE AVE STE 315
SHREVEPORT LA
71101-4621
US

IV. Provider business mailing address

2620 CENTENARY BLVD STE 312
SHREVEPORT LA
71104-3358
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-2828
  • Fax: 318-221-2998
Mailing address:
  • Phone: 318-681-9935
  • Fax: 318-221-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1376087320
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: