Provider Demographics
NPI:1477850667
Name:SAM, THOMANDRA SHAVAUN (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMANDRA
Middle Name:SHAVAUN
Last Name:SAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-330-0497
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:6400 PERKINS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4124
Practice Address - Country:US
Practice Address - Phone:225-330-0497
Practice Address - Fax:225-330-0498
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
LA1331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling