Provider Demographics
NPI:1659925626
Name:HOUSTON, FANETTA MAQUAIL
Entity Type:Individual
Prefix:
First Name:FANETTA
Middle Name:MAQUAIL
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 MILLICENT WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2237
Mailing Address - Country:US
Mailing Address - Phone:662-312-5913
Mailing Address - Fax:
Practice Address - Street 1:458 HERNDON ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4859
Practice Address - Country:US
Practice Address - Phone:318-429-6938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LAPLC7978171M00000X
LALPC7978101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator