Provider Demographics
NPI:1477925469
Name:WHITESIDE, MIA DESHAWN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:DESHAWN
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MIA
Other - Middle Name:DESHAWN
Other - Last Name:WHITESIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 EAST STONER AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-221-8411
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:915-742-4890
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX626081041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX62608OtherASSOCIATES OF SOCIAL WORK BOARD
NMC-09095OtherASSOCIATES OF SOCIAL WORK BOARD