Provider Demographics
NPI:1942797717
Name:GLOVER, ELICIA MICHELLE
Entity Type:Individual
Prefix:
First Name:ELICIA
Middle Name:MICHELLE
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9230 BLUE SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2211
Mailing Address - Country:US
Mailing Address - Phone:318-210-9017
Mailing Address - Fax:
Practice Address - Street 1:2800 YOUREE DR STE 482
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3666
Practice Address - Country:US
Practice Address - Phone:318-869-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health