Provider Demographics
NPI:1356319453
Name:WILLIAMSON, LARRIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LARRIE
Middle Name:ANN
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4143
Mailing Address - Country:US
Mailing Address - Phone:318-675-1300
Mailing Address - Fax:318-675-1301
Practice Address - Street 1:1002 HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4143
Practice Address - Country:US
Practice Address - Phone:318-675-1300
Practice Address - Fax:318-675-1301
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023926174400000X
LAMD.0239262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1487562Medicaid
LAH37763Medicare UPIN
LA1487562Medicaid