Provider Demographics
NPI:1114793064
Name:HEPBURN, TIA DANIELLE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:DANIELLE
Last Name:HEPBURN
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 1:8291 DAMES POINT CROSSING BLVD N APT 4310
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-3847
Mailing Address - Country:US
Mailing Address - Phone:480-662-2560
Mailing Address - Fax:
Practice Address - Street 1:8291 DAMES POINT CROSSING BLVD N APT 4310
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3847
Practice Address - Country:US
Practice Address - Phone:480-662-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHT.0100424101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health