Provider Demographics
NPI:1063609782
Name:GITHENS, ROSS (LAC 1144)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:GITHENS
Suffix:
Gender:M
Credentials:LAC 1144
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6129 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4833
Mailing Address - Country:US
Mailing Address - Phone:318-459-8922
Mailing Address - Fax:
Practice Address - Street 1:520 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2312
Practice Address - Country:US
Practice Address - Phone:318-459-8922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1144101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)