Provider Demographics
NPI:1588034581
Name:DHALIWAL, TISA (RSW)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:
Last Name:DHALIWAL
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8527
Mailing Address - Country:US
Mailing Address - Phone:318-343-8744
Mailing Address - Fax:
Practice Address - Street 1:645 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8527
Practice Address - Country:US
Practice Address - Phone:318-343-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11262261QM0801X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11262OtherLABSWE