Basic Information
| Provider Information | |||||||||
| NPI: | 1588034581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DHALIWAL | ||||||||
| FirstName: | TISA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183258748 | ||||||||
| FaxNumber: | 3183258749 | ||||||||
| Practice Location | |||||||||
| Address1: | 908 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183258748 | ||||||||
| FaxNumber: | 3183258749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 11262 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 11262 | 01 | LA | LABSWE | OTHER |