Provider Demographics
NPI:1386047462
Name:BENTON, SHAWANDA
Entity type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:
Last Name:BENTON
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 1:1215 INDEPENDENCE BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7391
Mailing Address - Country:US
Mailing Address - Phone:225-306-4488
Mailing Address - Fax:225-306-4390
Practice Address - Street 1:1215 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7390
Practice Address - Country:US
Practice Address - Phone:225-306-4488
Practice Address - Fax:225-306-4390
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5070101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional