=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275077257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY COLLABORATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2016
-----------------------------------------------------
Last Update Date | 12/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3825 GILBERT DR SUITE 135
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71104-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-207-0267
-----------------------------------------------------
Fax | 844-871-2020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3825 GILBERT DR SUITE 135
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71104-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-207-0267
-----------------------------------------------------
Fax | 844-871-2020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NAKIA SHANA THOMAS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 318-207-0267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 9568
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------