Basic Information
| Provider Information | |||||||||
| NPI: | 1770939506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAMPLEY | ||||||||
| FirstName: | WILLA | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STAMPLEY | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1705 FELICIA AVE | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712828203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185741232 | ||||||||
| FaxNumber: | 3185748646 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 FELICIA AVE | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185741232 | ||||||||
| FaxNumber: | 3185748646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.