Provider Demographics
NPI:1245815711
Name:BRAGG, TYREA D (OCPRS,)
Entity type:Individual
Prefix:
First Name:TYREA
Middle Name:D
Last Name:BRAGG
Suffix:
Gender:F
Credentials:OCPRS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45144-1562
Mailing Address - Country:US
Mailing Address - Phone:606-375-8957
Mailing Address - Fax:
Practice Address - Street 1:25201 CHAGRIN BLVD STE 390
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5637
Practice Address - Country:US
Practice Address - Phone:216-910-9015
Practice Address - Fax:216-910-9015
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002260175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty