Provider Demographics
NPI:1699209601
Name:SAVANNAH, DANTE
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:
Last Name:SAVANNAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107
Mailing Address - Country:US
Mailing Address - Phone:318-655-3047
Mailing Address - Fax:
Practice Address - Street 1:2146 PEARL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-8017
Practice Address - Country:US
Practice Address - Phone:318-655-3047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA009071719OtherDRIVERS LICENSE