Basic Information
Provider Information | |||||||||
NPI: | 1083060438 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARROLL | ||||||||
FirstName: | TWANA | ||||||||
MiddleName: | LATONYA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, MBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2924 KNIGHT ST STE 426 | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711052414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187543560 | ||||||||
FaxNumber: | 3187790439 | ||||||||
Practice Location | |||||||||
Address1: | 2924 KNIGHT ST STE 426 | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711052414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187543560 | ||||||||
FaxNumber: | 3187790439 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2016 | ||||||||
LastUpdateDate: | 04/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 1083060438 | LA | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1003549654 | 05 | LA |   | MEDICAID |