Healthcare Provider Details

I. General information

NPI: 1073035101
Provider Name (Legal Business Name): TIARRA D WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY LN
SHREVEPORT LA
71118-2556
US

IV. Provider business mailing address

2715 MACKEY LN
SHREVEPORT LA
71118-2556
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax: 318-220-8573
Mailing address:
  • Phone: 318-220-8423
  • Fax: 318-220-8573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: