Healthcare Provider Details

I. General information

NPI: 1275077257
Provider Name (Legal Business Name): COMMUNITY COLLABORATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3825 GILBERT DR SUITE 135
SHREVEPORT LA
71104-5000
US

IV. Provider business mailing address

3825 GILBERT DR SUITE 135
SHREVEPORT LA
71104-5000
US

V. Phone/Fax

Practice location:
  • Phone: 318-207-0267
  • Fax: 844-871-2020
Mailing address:
  • Phone: 318-207-0267
  • Fax: 844-871-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number9568
License Number StateLA

VIII. Authorized Official

Name: NAKIA SHANA THOMAS
Title or Position: OWNER
Credential: LCSW
Phone: 318-207-0267