Basic Information
| Provider Information | |||||||||
| NPI: | 1407213531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCRAY | ||||||||
| FirstName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 DUNBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189903493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2285 BENTON RD STE D103 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711113465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185847197 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2016 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.