Provider Demographics
NPI:1467960187
Name:GRUNDY, TIERRA NICHOLE (MA)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:NICHOLE
Last Name:GRUNDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14344 CAJON AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-4300
Mailing Address - Country:US
Mailing Address - Phone:760-243-3999
Mailing Address - Fax:760-243-9559
Practice Address - Street 1:14344 CAJON AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-4300
Practice Address - Country:US
Practice Address - Phone:760-243-3999
Practice Address - Fax:760-243-9559
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT103900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103900OtherBEHAVIORAL HEALTH