Provider Demographics
NPI:1285181032
Name:MAMOU, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:MAMOU
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:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-0749
Mailing Address - Country:US
Mailing Address - Phone:318-305-6233
Mailing Address - Fax:
Practice Address - Street 1:1140 SHIRLEY RD
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1545
Practice Address - Country:US
Practice Address - Phone:318-346-8001
Practice Address - Fax:318-346-8005
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679507412OtherNPI
LA1544761Medicaid