Provider Demographics
NPI:1114681905
Name:SHORTER, TAMIKKA ROSE
Entity Type:Individual
Prefix:
First Name:TAMIKKA
Middle Name:ROSE
Last Name:SHORTER
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 1:1191 ROSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7335
Mailing Address - Country:US
Mailing Address - Phone:225-620-9934
Mailing Address - Fax:
Practice Address - Street 1:1191 ROSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7335
Practice Address - Country:US
Practice Address - Phone:225-620-9934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No376J00000XNursing Service Related ProvidersHomemaker