Provider Demographics
NPI:1053925891
Name:SHERIDAN, TIESHA
Entity type:Individual
Prefix:
First Name:TIESHA
Middle Name:
Last Name:SHERIDAN
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 1:201 PAVILION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2691
Mailing Address - Country:US
Mailing Address - Phone:318-512-5124
Mailing Address - Fax:
Practice Address - Street 1:201 PAVILION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-2691
Practice Address - Country:US
Practice Address - Phone:318-512-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator