Individual
MRS. MARY TERESA WILLCOX
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CIT
Contact information
Practice address
1525 FULLILOVE DR, BOSSIER CITY, LA 71112-3346
(318) 747-1211
Mailing address
2000 FAIRFIELD AVE, SHREVEPORT, LA 71104-2002
(318) 222-8511
(318) 222-3278
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
3259
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1699955815
—
LA
Enumeration date
10/13/2017
Last updated
10/13/2017
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