Provider Demographics
NPI:1669007951
Name:LARCK, TAMARA 'TAMMY' (CIT)
Entity Type:Individual
Prefix:
First Name:TAMARA 'TAMMY'
Middle Name:
Last Name:LARCK
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2099
Mailing Address - Country:US
Mailing Address - Phone:318-222-8511
Mailing Address - Fax:318-425-9670
Practice Address - Street 1:1525 FULLILOVE DRIVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-747-1211
Practice Address - Fax:318-317-3333
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5061101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)