Provider Demographics
NPI:1194045179
Name:CAVINESS-ANDERSON, NACOSHA LEE
Entity Type:Individual
Prefix:
First Name:NACOSHA
Middle Name:LEE
Last Name:CAVINESS-ANDERSON
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 1:1323 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2044
Mailing Address - Country:US
Mailing Address - Phone:228-497-0690
Mailing Address - Fax:
Practice Address - Street 1:60 LOUIS PRIMA DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5903
Practice Address - Country:US
Practice Address - Phone:985-327-5427
Practice Address - Fax:985-327-8800
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
MSP324180164W00000X
LA7559171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse