Provider Demographics
NPI:1275208761
Name:NETTLES, ALISHA S
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:S
Last Name:NETTLES
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 1:908 W JUDGE PEREZ DR
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-4773
Mailing Address - Country:US
Mailing Address - Phone:504-324-5298
Mailing Address - Fax:504-309-2702
Practice Address - Street 1:908 W JUDGE PEREZ DR STE C
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-4773
Practice Address - Country:US
Practice Address - Phone:504-324-5298
Practice Address - Fax:504-309-2702
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1750754727Medicaid