Healthcare Provider Details

I. General information

NPI: 1932246360
Provider Name (Legal Business Name): TONYA MCBROOM RILEY LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5902 BUNCOMBE RD
SHREVEPORT LA
71129-4004
US

IV. Provider business mailing address

1101 E WASHINGTON ST
SHREVEPORT LA
71104-3821
US

V. Phone/Fax

Practice location:
  • Phone: 318-670-8898
  • Fax: 318-300-3772
Mailing address:
  • Phone: 318-393-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2979
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number979
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: