Provider Demographics
NPI:1750017919
Name:LUTTRELL, TIERRA VICTORIA (LMSW)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:VICTORIA
Last Name:LUTTRELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 E BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-3420
Mailing Address - Country:US
Mailing Address - Phone:573-286-2449
Mailing Address - Fax:
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:417-983-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022014071104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker