Provider Demographics
NPI:1932680345
Name:HOUSTON, PRISCILLA LENETTE (BS)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:LENETTE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0328
Mailing Address - Country:US
Mailing Address - Phone:601-870-7236
Mailing Address - Fax:
Practice Address - Street 1:1109 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3227
Practice Address - Country:US
Practice Address - Phone:318-336-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA640897031Medicaid