MEDICARE: TYRA TEASLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1508369448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA TEASLEY

Provider Business Mailing Address
First Line	:	2002 GUS KAPLAN DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3358
Country	:	US
Telephone Number	:	318-542-4642
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 GUS KAPLAN DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3358
Country	:	US
Telephone Number	:	318-542-4642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2018
Last Update Date	:	03/05/2019

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Directions to “ TYRA TEASLEY ” Practice Location

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