Provider Demographics
NPI:1467861377
Name:MASK, TIARA
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:MASK
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 1:720 W CHEYENNE AVE STE 30
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7817
Mailing Address - Country:US
Mailing Address - Phone:702-487-5665
Mailing Address - Fax:
Practice Address - Street 1:720 W CHEYENNE AVE STE 30
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7817
Practice Address - Country:US
Practice Address - Phone:702-487-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV560723071103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV560723071Medicaid