Provider Demographics
NPI:1659530319
Name:THE CHILDRENS COUNSELING CENTER OF SHREVEPORT INC
Entity Type:Organization
Organization Name:THE CHILDRENS COUNSELING CENTER OF SHREVEPORT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCENTEE
Authorized Official - Suffix:IV
Authorized Official - Credentials:LPC
Authorized Official - Phone:318-949-0951
Mailing Address - Street 1:225 MAHAFFEY RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:LA
Mailing Address - Zip Code:71067
Mailing Address - Country:US
Mailing Address - Phone:318-949-0951
Mailing Address - Fax:318-949-0951
Practice Address - Street 1:225 MAHAFFEY RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:LA
Practice Address - Zip Code:71067
Practice Address - Country:US
Practice Address - Phone:318-949-0951
Practice Address - Fax:318-949-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA552827OtherMAGELLAN
LA4434895890OtherBLUE CROSS OF LA