Healthcare Provider Details

I. General information

NPI: 1720658081
Provider Name (Legal Business Name): TYRA CHRISTINA HEDGEPETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 SAMUEL MORSE DR STE 150
COLUMBIA MD
21046-3420
US

IV. Provider business mailing address

4656 RIVERSTONE DR APT 204
OWINGS MILLS MD
21117-6991
US

V. Phone/Fax

Practice location:
  • Phone: 888-344-5977
  • Fax:
Mailing address:
  • Phone: 540-553-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number09588
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: