Basic Information
| Provider Information | |||||||||
| NPI: | 1336655141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYSON | ||||||||
| FirstName: | MARGUERITE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LMSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4919 CANAL ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701195878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044839883 | ||||||||
| FaxNumber: | 5044839082 | ||||||||
| Practice Location | |||||||||
| Address1: | 4919 CANAL ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044839883 | ||||||||
| FaxNumber: | 5044839082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2017 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 05 | LA | MEDICAID |