Basic Information
| Provider Information | |||||||||
| NPI: | 1710351853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | SHAUNTRICE | ||||||||
| MiddleName: | |||||||||
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| Credential: | A.S., MHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29372 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711499372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186708898 | ||||||||
| FaxNumber: | 3183003772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2285 BENTON RD STE D103 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711113465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185847197 | ||||||||
| FaxNumber: | 3185847080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2015 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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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 | LA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.