Provider Demographics
NPI:1184182065
Name:GREEN, TIARRA NICHELLE
Entity Type:Individual
Prefix:
First Name:TIARRA
Middle Name:NICHELLE
Last Name:GREEN
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 1:447 S SHARON AMITY RD STE 140
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2888
Mailing Address - Country:US
Mailing Address - Phone:704-900-9143
Mailing Address - Fax:704-364-6267
Practice Address - Street 1:447 S SHARON AMITY RD STE 140
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2888
Practice Address - Country:US
Practice Address - Phone:704-900-9143
Practice Address - Fax:704-364-6267
Is Sole Proprietor?:No
Enumeration Date:2019-03-09
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5441103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist