Healthcare Provider Details

I. General information

NPI: 1629569637
Provider Name (Legal Business Name): MS. TINA NICOLE CHAMBERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 KNIGHT ST STE 426
SHREVEPORT LA
71105
US

IV. Provider business mailing address

2827 JONATHAN LN
SHREVEPORT LA
71108-5531
US

V. Phone/Fax

Practice location:
  • Phone: 318-754-3560
  • Fax: 318-779-0439
Mailing address:
  • Phone: 318-347-4087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: