Provider Demographics
NPI:1003341371
Name:STILLS, A'LYECIA RUTH
Entity Type:Individual
Prefix:
First Name:A'LYECIA
Middle Name:RUTH
Last Name:STILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:A'LYECIA
Other - Middle Name:RUTH
Other - Last Name:IVORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2715 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4829
Mailing Address - Country:US
Mailing Address - Phone:318-505-3514
Mailing Address - Fax:
Practice Address - Street 1:1500 N MARKET ST
Practice Address - Street 2:UNIT C, SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6537
Practice Address - Country:US
Practice Address - Phone:318-626-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician