Provider Demographics
NPI:1114420072
Name:VANASSELBERG, LOUIS JACOB
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:JACOB
Last Name:VANASSELBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CLYDE FANT PARKWAY
Mailing Address - Street 2:SUITE 200 # 1040
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:877-360-7671
Mailing Address - Fax:
Practice Address - Street 1:401 EDWARDS ST STE 830
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-5528
Practice Address - Country:US
Practice Address - Phone:877-360-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA8498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator