Provider Demographics
NPI:1467942102
Name:THOMAS, TIAWANA
Entity Type:Individual
Prefix:MRS
First Name:TIAWANA
Middle Name:
Last Name:THOMAS
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 1:4601 N MARKET ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2972
Mailing Address - Country:US
Mailing Address - Phone:318-424-8735
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:318-746-2514
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA8868104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator