Provider Demographics
NPI:1518631134
Name:WILLS, KATHASHA FELICIA (BA SOCIAL WORK)
Entity Type:Individual
Prefix:
First Name:KATHASHA
Middle Name:FELICIA
Last Name:WILLS
Suffix:
Gender:F
Credentials:BA SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 CRESWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4774
Mailing Address - Country:US
Mailing Address - Phone:318-869-1899
Mailing Address - Fax:
Practice Address - Street 1:1519 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4774
Practice Address - Country:US
Practice Address - Phone:318-869-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1952846313Medicaid