Provider Demographics
NPI:1629749908
Name:WESTON, TEARRA EBONI
Entity Type:Individual
Prefix:
First Name:TEARRA
Middle Name:EBONI
Last Name:WESTON
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 1:3737 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3026
Mailing Address - Country:US
Mailing Address - Phone:262-595-8816
Mailing Address - Fax:
Practice Address - Street 1:3737 N 40TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3026
Practice Address - Country:US
Practice Address - Phone:262-595-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator