Provider Demographics
NPI:1861899387
Name:AUTRY, SHELIA
Entity type:Individual
Prefix:
First Name:SHELIA
Middle Name:
Last Name:AUTRY
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 1:257 CATTAIL TRL
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9719
Mailing Address - Country:US
Mailing Address - Phone:318-518-6969
Mailing Address - Fax:
Practice Address - Street 1:2285 BENTON RD STE D201
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3469
Practice Address - Country:US
Practice Address - Phone:318-518-6963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3556101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional