Provider Demographics
NPI:1629756267
Name:ROCKWELL, TIA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:ROCKWELL
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 1:3511 LONGMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-9334
Mailing Address - Country:US
Mailing Address - Phone:501-831-2195
Mailing Address - Fax:
Practice Address - Street 1:606 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-5140
Practice Address - Country:US
Practice Address - Phone:541-426-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health