Provider Demographics
NPI:1962917898
Name:BLOOD, NICOLETTE (BS, MPH)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:BLOOD
Suffix:
Gender:F
Credentials:BS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2538
Mailing Address - Country:US
Mailing Address - Phone:318-221-8244
Mailing Address - Fax:318-861-2162
Practice Address - Street 1:3007 KNIGHT ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2538
Practice Address - Country:US
Practice Address - Phone:318-221-8244
Practice Address - Fax:318-861-2162
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA72-0694376Medicaid