Provider Demographics
NPI:1457623530
Name:PIVONT, LINDA ANDERSON (LAC)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:ANDERSON
Last Name:PIVONT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7904
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7904
Mailing Address - Country:US
Mailing Address - Phone:318-676-5111
Mailing Address - Fax:318-676-5137
Practice Address - Street 1:1310 NORTH HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-676-5111
Practice Address - Fax:318-676-5137
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)