Basic Information
| Provider Information | |||||||||
| NPI: | 1104233253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS-GUIDRY | ||||||||
| FirstName: | TYESHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, RSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50140 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701500140 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 LOYOLA AVE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701131912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045589595 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2014 | ||||||||
| LastUpdateDate: | 07/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 600771346 | 05 | LA | MEDICAID |