Provider Demographics
NPI:1659828341
Name:PERKINS, SHANEL (MA)
Entity Type:Individual
Prefix:
First Name:SHANEL
Middle Name:
Last Name:PERKINS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:COVODKA
Other - Middle Name:SHANEL
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2302 MARION ST
Mailing Address - Street 2:SHREVEPORT
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3542
Mailing Address - Country:US
Mailing Address - Phone:318-820-2515
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-820-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health