Provider Demographics
NPI:1508388570
Name:COLLINS, TIARA ROUSSEL
Entity Type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:ROUSSEL
Last Name:COLLINS
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 1:401 MODERN FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WESTWEGO
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 MODERN FARMS RD
Practice Address - Street 2:
Practice Address - City:WESTWEGO
Practice Address - State:LA
Practice Address - Zip Code:70094-2371
Practice Address - Country:US
Practice Address - Phone:504-275-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1376805440Medicaid