Healthcare Provider Details

I. General information

NPI: 1871983866
Provider Name (Legal Business Name): TINA D CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 HIGHWAY 9
CAMPTI LA
71411
US

IV. Provider business mailing address

9245 WALLACE LAKE RD
SHREVEPORT LA
71106-7331
US

V. Phone/Fax

Practice location:
  • Phone: 318-476-2205
  • Fax: 318-476-2206
Mailing address:
  • Phone: 318-581-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number720408984
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: