Healthcare Provider Details

I. General information

NPI: 1396264107
Provider Name (Legal Business Name): MS. LISA REBECCA HAYES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 KNIGHT ST STE 2924
SHREVEPORT LA
71105-2415
US

IV. Provider business mailing address

5901 CANDLEWOOD LN
SHREVEPORT LA
71119-6303
US

V. Phone/Fax

Practice location:
  • Phone: 318-754-3560
  • Fax: 318-779-0439
Mailing address:
  • Phone: 318-426-1729
  • 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 TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: