Provider Demographics
NPI:1003348681
Name:SHOEMAKER, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 STAR ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-2012
Mailing Address - Country:US
Mailing Address - Phone:318-372-0016
Mailing Address - Fax:
Practice Address - Street 1:306 STAR ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-2012
Practice Address - Country:US
Practice Address - Phone:318-372-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health