Provider Demographics
NPI:1023839594
Name:MCCLURE, TYWANA
Entity type:Individual
Prefix:
First Name:TYWANA
Middle Name:
Last Name:MCCLURE
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 1:805 N BEECH ST STE 2805
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-3809
Mailing Address - Country:US
Mailing Address - Phone:318-493-5147
Mailing Address - Fax:318-493-5148
Practice Address - Street 1:805 N BEECH ST STE 2805
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3809
Practice Address - Country:US
Practice Address - Phone:318-493-5147
Practice Address - Fax:318-493-5148
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor