Provider Demographics
NPI:1164673760
Name:TYERRA MANOR, LLC RESIDENTIAL AGENCY
Entity Type:Organization
Organization Name:TYERRA MANOR, LLC RESIDENTIAL AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:SAFFIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:TUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-217-6996
Mailing Address - Street 1:1533 E SUNLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-3269
Mailing Address - Country:US
Mailing Address - Phone:602-268-2538
Mailing Address - Fax:602-268-2538
Practice Address - Street 1:1533 E SUNLAND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3269
Practice Address - Country:US
Practice Address - Phone:602-268-2538
Practice Address - Fax:602-268-2538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3122320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness