Provider Demographics
NPI:1841868031
Name:CLAIBORNE, SHASTITY
Entity type:Individual
Prefix:
First Name:SHASTITY
Middle Name:
Last Name:CLAIBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E ASKEW ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-3706
Mailing Address - Country:US
Mailing Address - Phone:318-574-2320
Mailing Address - Fax:
Practice Address - Street 1:410 E ASKEW ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3706
Practice Address - Country:US
Practice Address - Phone:318-574-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1972980514Medicaid