Healthcare Provider Details

I. General information

NPI: 1427667385
Provider Name (Legal Business Name): TIERENNY SHAW-RAGSDALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-211 PALI MOMI ST STE 520
AIEA HI
96701-4328
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-1070
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80357
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: