Provider Demographics
NPI:1033621917
Name:WILLIS, TIAIRA MIKAL
Entity Type:Individual
Prefix:
First Name:TIAIRA
Middle Name:MIKAL
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 HUDSON LN STE 202
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6032
Mailing Address - Country:US
Mailing Address - Phone:318-323-1300
Mailing Address - Fax:
Practice Address - Street 1:114 INEICHEN ST STE A
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3223
Practice Address - Country:US
Practice Address - Phone:318-417-7780
Practice Address - Fax:318-728-1140
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
LA7684101YP2500X
TX90118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator