Provider Demographics
NPI:1922763275
Name:FESTERVAN, LAURA SUSANNE (CIT,)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSANNE
Last Name:FESTERVAN
Suffix:
Gender:F
Credentials:CIT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3321
Practice Address - Country:US
Practice Address - Phone:318-816-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5525101YA0400X, 171M00000X
LA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist