Provider Demographics
NPI:1093368078
Name:TIERRA, AISHA
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:TIERRA
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 1:91-206 LOULULELO PL
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-3108
Mailing Address - Country:US
Mailing Address - Phone:808-294-7543
Mailing Address - Fax:
Practice Address - Street 1:95-732 MAIAKU ST
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-2816
Practice Address - Country:US
Practice Address - Phone:808-321-8105
Practice Address - Fax:808-623-6937
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-92036106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician