Healthcare Provider Details

I. General information

NPI: 1023839594
Provider Name (Legal Business Name): TYWANA MCCLURE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N BEECH ST STE 2805
TALLULAH LA
71282-3809
US

IV. Provider business mailing address

805 N BEECH ST STE 2805
TALLULAH LA
71282-3809
US

V. Phone/Fax

Practice location:
  • Phone: 318-493-5147
  • Fax: 318-493-5148
Mailing address:
  • Phone: 318-493-5147
  • Fax: 318-493-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: