Provider Demographics
NPI:1417737115
Name:QUINTANA, TYRA SHAE (MA LPC-MHSP (TEMP))
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:SHAE
Last Name:QUINTANA
Suffix:
Gender:F
Credentials:MA LPC-MHSP (TEMP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 MANCHESTER HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37357-7503
Mailing Address - Country:US
Mailing Address - Phone:931-815-3871
Mailing Address - Fax:
Practice Address - Street 1:5736 MANCHESTER HWY
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:TN
Practice Address - Zip Code:37357-7503
Practice Address - Country:US
Practice Address - Phone:931-815-3871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional