Basic Information
Provider Information | |||||||||
NPI: | 1346862547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATKINS | ||||||||
FirstName: | MALLORY | ||||||||
MiddleName: | NOELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MHS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOODS | ||||||||
OtherFirstName: | MALLORY | ||||||||
OtherMiddleName: | NOELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 LEE ST | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | LA | ||||||||
PostalCode: | 713016234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186257050 | ||||||||
FaxNumber: | 3186257197 | ||||||||
Practice Location | |||||||||
Address1: | 1500 LEE ST | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | LA | ||||||||
PostalCode: | 713016234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186257050 | ||||||||
FaxNumber: | 3186257197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2020 | ||||||||
LastUpdateDate: | 05/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | NONE | LA | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 0000 | 01 | LA | NONE | OTHER |