Basic Information
| Provider Information | |||||||||
| NPI: | 1033621917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | TIAIRA | ||||||||
| MiddleName: | MIKAL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1401 HUDSON LN STE 202 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183231300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 114 INEICHEN ST STE A | ||||||||
| Address2: | |||||||||
| City: | RAYVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712693223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184177780 | ||||||||
| FaxNumber: | 3187281140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 7684 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.