Healthcare Provider Details

I. General information

NPI: 1033621917
Provider Name (Legal Business Name): TIAIRA MIKAL WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 KILPATRICK BLVD STE 100
MONROE LA
71201-5156
US

IV. Provider business mailing address

3100 KILPATRICK BLVD STE 100
MONROE LA
71201-5156
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-8050
  • Fax:
Mailing address:
  • Phone: 318-325-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number90118
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7684
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: