Provider Demographics
NPI:1477093060
Name:ADDISON, INNIS
Entity Type:Individual
Prefix:
First Name:INNIS
Middle Name:
Last Name:ADDISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:INNIS
Other - Middle Name:
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M S
Mailing Address - Street 1:7607 FERN AVE STE 902
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5745
Mailing Address - Country:US
Mailing Address - Phone:318-524-9954
Mailing Address - Fax:
Practice Address - Street 1:200 N THOMAS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6503
Practice Address - Country:US
Practice Address - Phone:318-424-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health