Provider Demographics
NPI:1427173954
Name:NORTHSHORE COUNSELING AND WELLNESS LLC
Entity type:Organization
Organization Name:NORTHSHORE COUNSELING AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:SAGRERA
Authorized Official - Last Name:JUDICE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:985-624-2942
Mailing Address - Street 1:234 LAMARQUE ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5931
Mailing Address - Country:US
Mailing Address - Phone:985-624-2942
Mailing Address - Fax:985-231-1373
Practice Address - Street 1:671 RIVER HIGHLANDS BLVD STE 8
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8987
Practice Address - Country:US
Practice Address - Phone:985-624-2942
Practice Address - Fax:985-231-1373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2479101YM0800X
LA529106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA522331Medicare PIN