Provider Demographics
NPI:1841665890
Name:GIPSON, LEANDRE (MHP)
Entity type:Individual
Prefix:
First Name:LEANDRE
Middle Name:
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2022
Mailing Address - Country:US
Mailing Address - Phone:318-716-1369
Mailing Address - Fax:318-675-0120
Practice Address - Street 1:404 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-716-1369
Practice Address - Fax:318-675-0120
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 171M00000X
LA007657849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health