Healthcare Provider Details

I. General information

NPI: 1407663180
Provider Name (Legal Business Name): TIARA LASHAY BRAZILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 W 156TH ST STE 102
HARVEY IL
60426-4259
US

IV. Provider business mailing address

71 W 156TH ST STE 102
HARVEY IL
60426-4259
US

V. Phone/Fax

Practice location:
  • Phone: 708-825-9683
  • Fax: 708-825-9949
Mailing address:
  • Phone: 708-825-9683
  • Fax: 708-825-9949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041545418
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: