Provider Demographics
NPI:1912414848
Name:CLEMMONS, TIARA SHYRESE (BCABA)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:SHYRESE
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 JETT FERRY RD STE 400-197
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3059
Mailing Address - Country:US
Mailing Address - Phone:706-491-1497
Mailing Address - Fax:
Practice Address - Street 1:50 PLAZA WAY NW STE A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1141
Practice Address - Country:US
Practice Address - Phone:678-691-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0-19-9612106E00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst