Provider Demographics
NPI:1790447829
Name:HEARD, ELEXUS TIERRA
Entity Type:Individual
Prefix:
First Name:ELEXUS
Middle Name:TIERRA
Last Name:HEARD
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 1:2606 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-3073
Mailing Address - Country:US
Mailing Address - Phone:850-867-2559
Mailing Address - Fax:
Practice Address - Street 1:2606 LAUREL DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-3073
Practice Address - Country:US
Practice Address - Phone:850-867-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician