Provider Demographics
NPI:1316352180
Name:WITHERINGTON, INDIA
Entity type:Individual
Prefix:
First Name:INDIA
Middle Name:
Last Name:WITHERINGTON
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 1:1000 CHINABERRY DR STE 900
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:318-259-4676
Mailing Address - Fax:
Practice Address - Street 1:525 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2001
Practice Address - Country:US
Practice Address - Phone:318-259-4676
Practice Address - Fax:318-259-4677
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3333101YA0400X
LA1587101YA0400X
LA6443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1928756Medicaid