Healthcare Provider Details

I. General information

NPI: 1083060438
Provider Name (Legal Business Name): TWANA LATONYA CARROLL MA, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 KNIGHT ST STE 426
SHREVEPORT LA
71105-2414
US

IV. Provider business mailing address

2924 KNIGHT ST STE 426
SHREVEPORT LA
71105-2414
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1083060438
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: