Healthcare Provider Details

I. General information

NPI: 1154823375
Provider Name (Legal Business Name): TIFFANY WOODS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 01/03/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 TIGER DR
THIBODAUX LA
70301-4337
US

IV. Provider business mailing address

98 DIPLOMAT WAY
THIBODAUX LA
70301-4368
US

V. Phone/Fax

Practice location:
  • Phone: 985-449-4055
  • Fax:
Mailing address:
  • Phone: 985-665-0811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8336
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: