Basic Information
| Provider Information | |||||||||
| NPI: | 1487097630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTHONY | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MANY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714493717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182564119 | ||||||||
| FaxNumber: | 3182564171 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 LINWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186364194 | ||||||||
| FaxNumber: | 3186364196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | 3373 | LA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1710601 | 05 | LA | MEDICAID | 171M00000X | 05 | LA | MEDICAID |