Healthcare Provider Details

I. General information

NPI: 1134055882
Provider Name (Legal Business Name): TIARA RODRIGUEZ LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13421 S 37TH PL
PHOENIX AZ
85044-4540
US

IV. Provider business mailing address

3650 VIA DE LA REINA
SIERRA VISTA AZ
85650-8573
US

V. Phone/Fax

Practice location:
  • Phone: 602-715-0501
  • Fax:
Mailing address:
  • Phone: 928-502-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-22904
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: