Provider Demographics
NPI:1194806893
Name:HEACOCK, DONALD D (LCSW MSW)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:D
Last Name:HEACOCK
Suffix:
Gender:M
Credentials:LCSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:910 PIERREMONT ROAD
Mailing Address - Street 2:SUITE #357
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2063
Mailing Address - Country:US
Mailing Address - Phone:318-865-3199
Mailing Address - Fax:318-219-8260
Practice Address - Street 1:910 PIERREMONT ROAD
Practice Address - Street 2:SUITE #357
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2063
Practice Address - Country:US
Practice Address - Phone:318-865-3199
Practice Address - Fax:318-219-8260
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAS5087Medicare ID - Type Unspecified