Provider Demographics
NPI:1568848067
Name:SMITH, SONJA TULLOS (LAC 978)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:TULLOS
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC 978
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-2117
Mailing Address - Country:US
Mailing Address - Phone:985-517-1711
Mailing Address - Fax:985-747-8836
Practice Address - Street 1:804 N 2ND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2117
Practice Address - Country:US
Practice Address - Phone:985-517-1711
Practice Address - Fax:985-747-8836
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA978101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)