Provider Demographics
NPI:1770139511
Name:HARTLEY, TIAA C (DAC, LAC)
Entity type:Individual
Prefix:MRS
First Name:TIAA
Middle Name:C
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:DAC, LAC
Other - Prefix:MRS
Other - First Name:TIA
Other - Middle Name:APRIL
Other - Last Name:CURTIS-HARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAC, LAC
Mailing Address - Street 1:1123 STATE ROUTE 3 N STE 282
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1715
Mailing Address - Country:US
Mailing Address - Phone:301-580-4585
Mailing Address - Fax:240-366-5954
Practice Address - Street 1:1629 CROFTON CTR STE 18
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1318
Practice Address - Country:US
Practice Address - Phone:301-580-4585
Practice Address - Fax:240-366-5954
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA-3087586
MDU02667171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD764013700Medicaid