Provider Demographics
NPI:1477099281
Name:HARRELL, TYRA C (LAT)
Entity Type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:C
Last Name:HARRELL
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:MISS
Other - First Name:TYRA
Other - Middle Name:ROCHELLE
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT
Mailing Address - Street 1:19123 FOREST TRACE DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-5045
Mailing Address - Country:US
Mailing Address - Phone:832-419-4035
Mailing Address - Fax:
Practice Address - Street 1:19123 FOREST TRACE DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-5045
Practice Address - Country:US
Practice Address - Phone:832-419-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer