Provider Demographics
NPI:1912519083
Name:WILLIAMS, TASHARA D
Entity Type:Individual
Prefix:MRS
First Name:TASHARA
Middle Name:D
Last Name:WILLIAMS
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 1:3615 CRESTVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-6522
Mailing Address - Country:US
Mailing Address - Phone:940-230-0211
Mailing Address - Fax:
Practice Address - Street 1:3615 CRESTVIEW CIR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-6522
Practice Address - Country:US
Practice Address - Phone:940-230-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA282572164W00000X
LA6472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No164W00000XNursing Service ProvidersLicensed Practical Nurse