Provider Demographics
NPI:1558825513
Name:PENSON, TI'ARA T
Entity Type:Individual
Prefix:
First Name:TI'ARA
Middle Name:T
Last Name:PENSON
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 1:1591 BRUCKNER BLVD APT 14H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-6431
Mailing Address - Country:US
Mailing Address - Phone:347-987-5320
Mailing Address - Fax:
Practice Address - Street 1:1591 BRUCKNER BLVD APT 14H
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-6431
Practice Address - Country:US
Practice Address - Phone:347-987-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S000000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY932397413OtherGHI