Provider Demographics
NPI:1669550521
Name:GHANTA, SUPRIYA (MD)
Entity type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:GHANTA
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:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71496-1526
Mailing Address - Country:US
Mailing Address - Phone:337-238-6431
Mailing Address - Fax:337-238-1526
Practice Address - Street 1:103 BELVIEW RD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-2902
Practice Address - Country:US
Practice Address - Phone:337-238-6431
Practice Address - Fax:337-238-7070
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL05605R103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1328006Medicaid
LAL05605ROtherSTATE LICENCE NUMBER
LA51014 B510Medicare ID - Type Unspecified
LA1328006Medicaid