Provider Demographics
NPI:1285187971
Name:DU BOSE, TYRA RENEE
Entity Type:Individual
Prefix:MS
First Name:TYRA
Middle Name:RENEE
Last Name:DU BOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYRA
Other - Middle Name:RENEE
Other - Last Name:KNOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 631774
Mailing Address - Street 2:
Mailing Address - City:LANAI CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96763-1774
Mailing Address - Country:US
Mailing Address - Phone:808-649-0869
Mailing Address - Fax:
Practice Address - Street 1:555 FRASER AVE
Practice Address - Street 2:
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763-1774
Practice Address - Country:US
Practice Address - Phone:808-649-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst