Provider Demographics
NPI:1710101373
Name:NOLAN, REBECCA FAYE (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:FAYE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4203
Mailing Address - Country:US
Mailing Address - Phone:318-865-3482
Mailing Address - Fax:
Practice Address - Street 1:111 CARROLL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4203
Practice Address - Country:US
Practice Address - Phone:318-865-3482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA793MP103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)