Provider Demographics
NPI:1235990409
Name:UPSHUR, TIARA
Entity Type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:
Last Name:UPSHUR
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 1:36 FLETCHER DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-7440
Mailing Address - Country:US
Mailing Address - Phone:540-424-4265
Mailing Address - Fax:
Practice Address - Street 1:10712 BALLANTRAYE DR STE 310
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-4702
Practice Address - Country:US
Practice Address - Phone:540-765-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health