Provider Demographics
NPI:1295269363
Name:WILBURN, SMOKEY
Entity type:Individual
Prefix:
First Name:SMOKEY
Middle Name:
Last Name:WILBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 BULLARD AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-4918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4480 GENERAL DEGAULLE DR
Practice Address - Street 2:SUITE #219
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131-6941
Practice Address - Country:US
Practice Address - Phone:504-564-1290
Practice Address - Fax:504-564-1294
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health