Healthcare Provider Details

I. General information

NPI: 1144901034
Provider Name (Legal Business Name): TAMARA SHERICE CROW X
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 EAST MARTIN LUTHER KING ROAD
CHARENTON LA
70523
US

IV. Provider business mailing address

PO BOX 126
CHARENTON LA
70523-0126
US

V. Phone/Fax

Practice location:
  • Phone: 318-209-8232
  • Fax:
Mailing address:
  • Phone: 318-209-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5670
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: