Basic Information
| Provider Information | |||||||||
| NPI: | 1396281077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TISHLINN S FOUNTAIN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | T.A. SIMS THERAPY & SUPPORT SERVICES LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 401 WHITNEY AVE | ||||||||
| Address2: | STE 409 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700562558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043629010 | ||||||||
| FaxNumber: | 5043629070 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 WHITNEY AVE | ||||||||
| Address2: | STE 409 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700562558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043629010 | ||||||||
| FaxNumber: | 5043629070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2017 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOUNTAIN | ||||||||
| AuthorizedOfficialFirstName: | TISHLINN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5043129388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5971 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.