Provider Demographics
NPI:1659005197
Name:HALL, TIA IMAN SOJOURNER (BEHAVIORAL TECH)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:IMAN SOJOURNER
Last Name:HALL
Suffix:
Gender:F
Credentials:BEHAVIORAL TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17831 CRYSTAL PRESERVE DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6408
Mailing Address - Country:US
Mailing Address - Phone:813-753-9084
Mailing Address - Fax:
Practice Address - Street 1:12725 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1314
Practice Address - Country:US
Practice Address - Phone:813-467-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician