Provider Demographics
NPI:1548708068
Name:WAITE, SHANE E
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:E
Last Name:WAITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:LA
Mailing Address - Zip Code:70441-0216
Mailing Address - Country:US
Mailing Address - Phone:225-222-3341
Mailing Address - Fax:225-222-3368
Practice Address - Street 1:33 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:LA
Practice Address - Zip Code:70441
Practice Address - Country:US
Practice Address - Phone:225-222-3341
Practice Address - Fax:225-222-3368
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
LA15309104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker