Provider Demographics
NPI:1801402078
Name:BOOKER, TIA MARIE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:MARIE
Last Name:BOOKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:MARIE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5575 SIMMONS ST STE 1-491
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-9009
Mailing Address - Country:US
Mailing Address - Phone:702-283-6215
Mailing Address - Fax:702-979-1028
Practice Address - Street 1:7560 W SAHARA AVE STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2745
Practice Address - Country:US
Practice Address - Phone:702-476-2633
Practice Address - Fax:702-979-1028
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-20-144192106S00000X
NVRBT1462106S00000X
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician