Basic Information
| Provider Information | |||||||||
| NPI: | 1801389879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOSS | ||||||||
| FirstName: | TANYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3444 WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016380031 | ||||||||
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| Practice Location | |||||||||
| Address1: | 712 FIRST ST | ||||||||
| Address2: | |||||||||
| City: | DELHI | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712322421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188786696 | ||||||||
| FaxNumber: | 3188786698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2018 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00018215 | 05 | MS | MEDICAID |