Provider Demographics
NPI:1588222772
Name:SELF, TIESSA LURAE
Entity Type:Individual
Prefix:
First Name:TIESSA
Middle Name:LURAE
Last Name:SELF
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 1:927 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77506-4821
Mailing Address - Country:US
Mailing Address - Phone:346-308-0720
Mailing Address - Fax:
Practice Address - Street 1:927 STRAWBERRY RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77506-4821
Practice Address - Country:US
Practice Address - Phone:346-308-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001031032471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography