Provider Demographics
NPI:1003580242
Name:AIRHART, MELISSA ANNE DAMEWORTH
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE DAMEWORTH
Last Name:AIRHART
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 1:7330 FERN AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4988
Mailing Address - Country:US
Mailing Address - Phone:318-290-3331
Mailing Address - Fax:
Practice Address - Street 1:7330 FERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4971
Practice Address - Country:US
Practice Address - Phone:318-290-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician