Provider Demographics
NPI:1770278970
Name:ISSA, IBTISAM N
Entity type:Individual
Prefix:
First Name:IBTISAM
Middle Name:N
Last Name:ISSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:ISSA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:925 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2103
Mailing Address - Country:US
Mailing Address - Phone:318-300-3560
Mailing Address - Fax:318-300-3561
Practice Address - Street 1:925 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2103
Practice Address - Country:US
Practice Address - Phone:318-300-3560
Practice Address - Fax:318-300-3561
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-691103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst