Healthcare Provider Details

I. General information

NPI: 1346178365
Provider Name (Legal Business Name): SANERICA TANISHA GIPSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 SHED RD APT 126D
BOSSIER CITY LA
71111-3307
US

IV. Provider business mailing address

PO BOX 5097
BOSSIER CITY LA
71171-5097
US

V. Phone/Fax

Practice location:
  • Phone: 318-455-8291
  • Fax:
Mailing address:
  • Phone: 318-455-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6854
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: