Provider Demographics
NPI:1235703885
Name:LOCKETT-BRADLEY, D'SHANTI
Entity Type:Individual
Prefix:
First Name:D'SHANTI
Middle Name:
Last Name:LOCKETT-BRADLEY
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 1:8536 PANATELLA LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-5810
Mailing Address - Country:US
Mailing Address - Phone:318-572-9973
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL STE 119
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2527
Practice Address - Country:US
Practice Address - Phone:318-771-7707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator