Provider Demographics
NPI:1275249500
Name:NELSON, TIANNA GRACE
Entity Type:Individual
Prefix:
First Name:TIANNA
Middle Name:GRACE
Last Name:NELSON
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 1:920 W FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3749
Mailing Address - Country:US
Mailing Address - Phone:951-391-9494
Mailing Address - Fax:
Practice Address - Street 1:24081 SANDY GLADE AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-5529
Practice Address - Country:US
Practice Address - Phone:951-391-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician