Provider Demographics
NPI: | 1881224608 |
---|---|
Name: | SHELLEY VISCONTE, PSYCHOLOGIST, L.L.C. |
Entity Type: | Organization |
Organization Name: | SHELLEY VISCONTE, PSYCHOLOGIST, L.L.C. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KIMBER |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | FULLER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 318-425-2000 |
Mailing Address - Street 1: | 3341 YOUREE DR STE 20A |
Mailing Address - Street 2: | |
Mailing Address - City: | SHREVEPORT |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 71105-2149 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 318-425-2000 |
Mailing Address - Fax: | 318-424-2601 |
Practice Address - Street 1: | 3341 YOUREE DR STE 20A |
Practice Address - Street 2: | |
Practice Address - City: | SHREVEPORT |
Practice Address - State: | LA |
Practice Address - Zip Code: | 71105-2149 |
Practice Address - Country: | US |
Practice Address - Phone: | 318-425-2000 |
Practice Address - Fax: | 318-424-2601 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-01-21 |
Last Update Date: | 2020-01-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |