Provider Demographics
NPI:1083060438
Name:CARROLL, TWANA LATONYA (MA, MBA)
Entity Type:Individual
Prefix:
First Name:TWANA
Middle Name:LATONYA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MA, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 KNIGHT ST STE 426
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2414
Mailing Address - Country:US
Mailing Address - Phone:318-754-3560
Mailing Address - Fax:318-779-0439
Practice Address - Street 1:2924 KNIGHT ST STE 426
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2414
Practice Address - Country:US
Practice Address - Phone:318-754-3560
Practice Address - Fax:318-779-0439
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1083060438171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1003549654Medicaid