Provider Demographics
NPI:1942224530
Name:UNDERWOOD, DONNIE MACK JR (EDS)
Entity Type:Individual
Prefix:MR
First Name:DONNIE
Middle Name:MACK
Last Name:UNDERWOOD
Suffix:JR
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:LA
Mailing Address - Zip Code:71001-3515
Mailing Address - Country:US
Mailing Address - Phone:318-263-8131
Mailing Address - Fax:318-263-8364
Practice Address - Street 1:1595 1ST ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-3515
Practice Address - Country:US
Practice Address - Phone:318-263-8131
Practice Address - Fax:318-263-8364
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2020101YP2500X
LA405106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist