Provider Demographics
NPI:1881368306
Name:THIERRY, TAWANNA
Entity type:Individual
Prefix:DR
First Name:TAWANNA
Middle Name:
Last Name:THIERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4439
Mailing Address - Country:US
Mailing Address - Phone:713-859-4958
Mailing Address - Fax:337-513-8891
Practice Address - Street 1:3823 E TRADITIONS CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-3961
Practice Address - Country:US
Practice Address - Phone:713-859-4958
Practice Address - Fax:337-513-8891
Is Sole Proprietor?:No
Enumeration Date:2021-08-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX18813683062084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030483402Medicaid