Provider Demographics
NPI:1013524875
Name:FARGERSON, ELIZABETH MAE (BCABA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:FARGERSON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4235
Mailing Address - Country:US
Mailing Address - Phone:318-230-0865
Mailing Address - Fax:
Practice Address - Street 1:9441 STEVENS RD STE 150
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7574
Practice Address - Country:US
Practice Address - Phone:318-947-9000
Practice Address - Fax:318-692-3904
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-694103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty