Provider Demographics
NPI:1073242764
Name:COLLINS, TIARRA SHENELLE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:TIARRA
Middle Name:SHENELLE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CHASE GAYTON CIR APT 636
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-6531
Mailing Address - Country:US
Mailing Address - Phone:757-927-0121
Mailing Address - Fax:
Practice Address - Street 1:23 CHASE GAYTON CIR APT 636
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-6531
Practice Address - Country:US
Practice Address - Phone:757-927-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist