Healthcare Provider Details

I. General information

NPI: 1912519083
Provider Name (Legal Business Name): MRS. TASHARA D WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CRESTVIEW CIR
SHREVEPORT LA
71119-6522
US

IV. Provider business mailing address

3615 CRESTVIEW CIR
SHREVEPORT LA
71119-6522
US

V. Phone/Fax

Practice location:
  • Phone: 940-230-0211
  • Fax:
Mailing address:
  • Phone: 940-230-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6472
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number282572
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: