Provider Demographics
NPI:1114771318
Name:STEVENS, TIERRA SHANICE
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:SHANICE
Last Name:STEVENS
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 1:22515 JACKSON CT APT 4D
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2112
Mailing Address - Country:US
Mailing Address - Phone:708-949-0447
Mailing Address - Fax:
Practice Address - Street 1:1385 HWY 35 # 284
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2012
Practice Address - Country:US
Practice Address - Phone:708-540-6976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician