Basic Information
| Provider Information | |||||||||
| NPI: | 1962856021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDMON | ||||||||
| FirstName: | SHANAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2448 JOHNSTON ST | ||||||||
| Address2: | STE B | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372337250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2448 JOHNSTON ST | ||||||||
| Address2: | STE B | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372337250 | ||||||||
| FaxNumber: | 3372337104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 600720410 | 05 | LA | MEDICAID |