Provider Demographics
NPI:1376020370
Name:WARE, CARRIE J
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:J
Last Name:WARE
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 1:2605 BETTY ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5553
Mailing Address - Country:US
Mailing Address - Phone:501-309-6361
Mailing Address - Fax:318-865-2312
Practice Address - Street 1:2605 BETTY ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-5553
Practice Address - Country:US
Practice Address - Phone:318-865-2311
Practice Address - Fax:318-865-2312
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1038610Medicaid