Provider Demographics
NPI:1619441565
Name:DR. TIFFANY ZACHERY, LLC
Entity Type:Organization
Organization Name:DR. TIFFANY ZACHERY, LLC
Other - Org Name:DR. TIFFANY ZACHERY, LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:SHARELL
Authorized Official - Last Name:ZACHERY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:337-290-9868
Mailing Address - Street 1:PO BOX 62506
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70596-2506
Mailing Address - Country:US
Mailing Address - Phone:337-290-9868
Mailing Address - Fax:
Practice Address - Street 1:110 TRAVIS STREET
Practice Address - Street 2:SUITE 113
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2452
Practice Address - Country:US
Practice Address - Phone:225-614-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA113371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1033690102Medicaid
LA1033690102OtherMEDICARE