Provider Demographics
NPI:1992151542
Name:NORDBERG, MARY LOWERY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOWERY
Last Name:NORDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1506
Mailing Address - Country:US
Mailing Address - Phone:318-393-4089
Mailing Address - Fax:318-681-4657
Practice Address - Street 1:2915 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-4327
Practice Address - Country:US
Practice Address - Phone:318-621-8820
Practice Address - Fax:318-212-4189
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No170300000XOther Service ProvidersGenetic Counselor, MS