=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508055187
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDI LEIGH JOHNSON LABORDE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2007
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2620 CENTENARY BLVD STE 120
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71104-3349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-227-9225
-----------------------------------------------------
Fax | 318-227-9997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 79885 CIEGO DR
-----------------------------------------------------
City | BERMUDA DUNES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92203-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-470-8783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1006
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY27494
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------