Basic Information
Provider Information | |||||||||
NPI: | 1376815340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOUSHON | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARPER | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3650 GREENWAY PL | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711052012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3184690053 | ||||||||
FaxNumber: | 3186819938 | ||||||||
Practice Location | |||||||||
Address1: | 2620 CENTENARY BLVD | ||||||||
Address2: | BUILDING 3, SUITE 312 | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711043356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186819935 | ||||||||
FaxNumber: | 3186819938 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2012 | ||||||||
LastUpdateDate: | 02/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4017 | LA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 4017 | LA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 4017 | 01 | LA | LICENSED PROFESSIONAL COUNSELOR | OTHER |