Basic Information
| Provider Information | |||||||||
| NPI: | 1275907560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACE | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4571 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711072917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248735 | ||||||||
| FaxNumber: | 3184248739 | ||||||||
| Practice Location | |||||||||
| Address1: | 4571 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248735 | ||||||||
| FaxNumber: | 3184248739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2015 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 13911 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1417252230 | 05 | LA | MEDICAID |