Provider Demographics
NPI:1396555777
Name:NIBLACK, TEZRA N
Entity type:Individual
Prefix:
First Name:TEZRA
Middle Name:N
Last Name:NIBLACK
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 1:9002 WHITE PICKETT CT
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-4760
Mailing Address - Country:US
Mailing Address - Phone:202-883-2605
Mailing Address - Fax:
Practice Address - Street 1:9002 WHITE PICKETT CT
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-4760
Practice Address - Country:US
Practice Address - Phone:202-883-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional