Provider Demographics
NPI:1356618847
Name:WOOTEN, LASHONDA FONTA (PSYD)
Entity type:Individual
Prefix:DR
First Name:LASHONDA
Middle Name:FONTA
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 95TH ST APT 1224
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-1599
Mailing Address - Country:US
Mailing Address - Phone:870-489-9780
Mailing Address - Fax:
Practice Address - Street 1:13151 EMILY RD
Practice Address - Street 2:STE. 240
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-690-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35110103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical