Provider Demographics
NPI:1295182194
Name:DICKERSON, TYIANA RENEE
Entity Type:Individual
Prefix:
First Name:TYIANA
Middle Name:RENEE
Last Name:DICKERSON
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 1:122 SCHOOLHOUSE RD
Mailing Address - Street 2:APT. 5
Mailing Address - City:CLOUTIERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71416-2019
Mailing Address - Country:US
Mailing Address - Phone:504-512-0778
Mailing Address - Fax:
Practice Address - Street 1:3018 OLD MINDEN RD STE 1117
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2497
Practice Address - Country:US
Practice Address - Phone:318-746-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health