Provider Demographics
NPI:1326088535
Name:ROBERTS, TIARA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIARA
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3776
Mailing Address - Country:US
Mailing Address - Phone:817-444-3603
Mailing Address - Fax:817-406-4140
Practice Address - Street 1:317 N BROADWAY RD
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3776
Practice Address - Country:US
Practice Address - Phone:817-444-3603
Practice Address - Fax:817-406-4140
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222537103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DO5ROtherBLUE CROSS/BLUE SHIELD
TX032590401Medicaid
TX00DO5ROtherBLUE CROSS/BLUE SHIELD