Provider Demographics
NPI:1447617550
Name:CLARK, SHANIKA
Entity type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:CLARK
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 1:800 SPRING ST STE 215
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3757
Mailing Address - Country:US
Mailing Address - Phone:318-227-8390
Mailing Address - Fax:318-428-2414
Practice Address - Street 1:2620 CENTENARY BLVD STE 312
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3358
Practice Address - Country:US
Practice Address - Phone:318-681-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
LAPLC10022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator