Provider Demographics
NPI:1942585609
Name:MEDICA, SAM ANTHONY (LPC)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:ANTHONY
Last Name:MEDICA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 7904
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7904
Mailing Address - Country:US
Mailing Address - Phone:318-676-5111
Mailing Address - Fax:318-676-5021
Practice Address - Street 1:1310 NORTH HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-676-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker