Provider Demographics
NPI:1851094668
Name:DANIELS, TIERRA JANAE
Entity Type:Individual
Prefix:MRS
First Name:TIERRA
Middle Name:JANAE
Last Name:DANIELS
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 1:2045 W GRAND AVE STE B PMB 424299
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1577
Mailing Address - Country:US
Mailing Address - Phone:312-210-0184
Mailing Address - Fax:
Practice Address - Street 1:2045 W GRAND AVE STE B PMB 424299
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1577
Practice Address - Country:US
Practice Address - Phone:312-210-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018978101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional