Provider Demographics
NPI:1932616661
Name:TISBY, SAMARIA RANDLE
Entity Type:Individual
Prefix:
First Name:SAMARIA
Middle Name:RANDLE
Last Name:TISBY
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 1:1632 SHEPHERD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4955
Mailing Address - Country:US
Mailing Address - Phone:318-415-8414
Mailing Address - Fax:
Practice Address - Street 1:1632 SHEPHERD DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-4955
Practice Address - Country:US
Practice Address - Phone:318-415-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health