Provider Demographics
NPI:1265110589
Name:PETRUS, TIERRA
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:PETRUS
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 1:6416 ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1837
Mailing Address - Country:US
Mailing Address - Phone:781-664-3400
Mailing Address - Fax:
Practice Address - Street 1:6416 ROBERT DR
Practice Address - Street 2:
Practice Address - City:SOUTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02375-1837
Practice Address - Country:US
Practice Address - Phone:781-664-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician