Provider Demographics
NPI:1982189957
Name:MINGO, FREDDIE
Entity Type:Individual
Prefix:
First Name:FREDDIE
Middle Name:
Last Name:MINGO
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 1:8370 OLD MOORINGSPORT RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-9273
Mailing Address - Country:US
Mailing Address - Phone:318-422-5567
Mailing Address - Fax:
Practice Address - Street 1:8370 OLD MOORINGSPORT RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-9273
Practice Address - Country:US
Practice Address - Phone:318-422-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2021-05-25
Deactivation Date:2020-04-17
Deactivation Code:
Reactivation Date:2021-05-25
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health