Provider Demographics
NPI:1487097630
Name:ANTHONY, LORA N
Entity type:Individual
Prefix:MISS
First Name:LORA
Middle Name:N
Last Name:ANTHONY
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 1:265 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-3717
Mailing Address - Country:US
Mailing Address - Phone:318-256-4119
Mailing Address - Fax:318-256-4171
Practice Address - Street 1:3510 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-636-4194
Practice Address - Fax:318-636-4196
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LA3373390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710601Medicaid
LA171M00000XMedicaid