Provider Demographics
NPI:1376815340
Name:MOUSHON, AMANDA MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARIE
Last Name:MOUSHON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3650 GREENWAY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2012
Mailing Address - Country:US
Mailing Address - Phone:318-469-0053
Mailing Address - Fax:318-681-9938
Practice Address - Street 1:2620 CENTENARY BLVD
Practice Address - Street 2:BUILDING 3, SUITE 312
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3356
Practice Address - Country:US
Practice Address - Phone:318-681-9935
Practice Address - Fax:318-681-9938
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4017101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4017OtherLICENSED PROFESSIONAL COUNSELOR