Provider Demographics
NPI:1538121611
Name:KILLGORE, MEDA ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MEDA
Middle Name:ANN
Last Name:KILLGORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 JEFFERSON OAKS DR
Mailing Address - Street 2:RUSTON
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-7083
Mailing Address - Country:US
Mailing Address - Phone:318-255-5145
Mailing Address - Fax:318-255-1189
Practice Address - Street 1:124 KILGORE RD
Practice Address - Street 2:RUSTON
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-7084
Practice Address - Country:US
Practice Address - Phone:318-251-1418
Practice Address - Fax:318-255-1189
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical