Provider Demographics
NPI:1164959854
Name:PEREZ, TIARA ANNETTE (CADC)
Entity Type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:ANNETTE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:MS
Other - First Name:TIARA
Other - Middle Name:ANNETTE
Other - Last Name:FORMARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 658
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501
Mailing Address - Country:US
Mailing Address - Phone:641-683-6747
Mailing Address - Fax:641-683-6317
Practice Address - Street 1:310 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-683-6747
Practice Address - Fax:641-683-6317
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)