Provider Demographics
NPI:1407998370
Name:FARGERSON, SANDRA SMITH (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SMITH
Last Name:FARGERSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 DEVEREAUX DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6128
Mailing Address - Country:US
Mailing Address - Phone:318-742-3895
Mailing Address - Fax:
Practice Address - Street 1:900 PIERREMONT RD
Practice Address - Street 2:SUITE 217
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2044
Practice Address - Country:US
Practice Address - Phone:318-868-1165
Practice Address - Fax:318-868-1180
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional