Provider Demographics
NPI:1275032591
Name:WARE, TAMEKA
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:
Last Name:WARE
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 1:1543 GRIMMETT DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6505
Mailing Address - Country:US
Mailing Address - Phone:318-626-5597
Mailing Address - Fax:
Practice Address - Street 1:1543 GRIMMETT DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6505
Practice Address - Country:US
Practice Address - Phone:318-626-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-10-01
Deactivation Date:2018-02-05
Deactivation Code:
Reactivation Date:2018-03-13
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health