Healthcare Provider Details

I. General information

NPI: 1225540529
Provider Name (Legal Business Name): TONYA WILLIAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 LINE AVE STE 207
SHREVEPORT LA
71104-2134
US

IV. Provider business mailing address

2210 LINE AVE STE 207
SHREVEPORT LA
71104-2134
US

V. Phone/Fax

Practice location:
  • Phone: 318-773-7661
  • Fax: 866-307-9980
Mailing address:
  • Phone: 318-675-1112
  • Fax: 866-307-9980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONYA WRIGHT WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential: LICENSED
Phone: 318-773-7661