Provider Demographics
NPI:1831656503
Name:BOLEY, TIERRA
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:BOLEY
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 1:17109 RUFFIN RD
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444-7561
Mailing Address - Country:US
Mailing Address - Phone:985-514-4310
Mailing Address - Fax:
Practice Address - Street 1:1312 N. MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401
Practice Address - Country:US
Practice Address - Phone:385-514-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA601156612171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator