Provider Demographics
NPI:1497230957
Name:PROVO, TIANDRA L (MHS)
Entity Type:Individual
Prefix:
First Name:TIANDRA
Middle Name:L
Last Name:PROVO
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:TIANDRA
Other - Middle Name:
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11861 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4404
Mailing Address - Country:US
Mailing Address - Phone:225-612-8656
Mailing Address - Fax:
Practice Address - Street 1:216 LOBDELL AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4612
Practice Address - Country:US
Practice Address - Phone:225-439-8198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician