Provider Demographics
NPI:1619609310
Name:BRACEY, TIARA
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:BRACEY
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 1:6691 CHURCH ST UNIT 960843
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-4033
Mailing Address - Country:US
Mailing Address - Phone:678-437-7350
Mailing Address - Fax:
Practice Address - Street 1:6071 HIGHWAY 85 APT 31A
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-1531
Practice Address - Country:US
Practice Address - Phone:678-437-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000000405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional