Provider Demographics
NPI:1013586247
Name:IVEY, TIAJANAE
Entity Type:Individual
Prefix:
First Name:TIAJANAE
Middle Name:
Last Name:IVEY
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 1:6718 GLEN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-1940
Mailing Address - Country:US
Mailing Address - Phone:510-850-4025
Mailing Address - Fax:
Practice Address - Street 1:2751 NAPA VALLEY CORPORATE DR BLDG B
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6216
Practice Address - Country:US
Practice Address - Phone:707-210-2437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator