Basic Information
| Provider Information | |||||||||
| NPI: | 1568916534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOFFITT | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 YOUREE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186570804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 WEST ST | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184354651 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2016 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 11568916534 | 05 | LA | MEDICAID | 1568916534 | 05 | LA | MEDICAID |