Provider Demographics
NPI:1164204327
Name:VALLERY, LA'TAVIA TINIA
Entity Type:Individual
Prefix:
First Name:LA'TAVIA
Middle Name:TINIA
Last Name:VALLERY
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 1:804 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GUEYDAN
Mailing Address - State:LA
Mailing Address - Zip Code:70542-3206
Mailing Address - Country:US
Mailing Address - Phone:337-275-0610
Mailing Address - Fax:
Practice Address - Street 1:10473 OLD HAMMOND HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8264
Practice Address - Country:US
Practice Address - Phone:225-924-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT-5719101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)