Healthcare Provider Details

I. General information

NPI: 1033756234
Provider Name (Legal Business Name): TIERRA SHOPE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WOOD ST
CLARION PA
16214-1232
US

IV. Provider business mailing address

918 SCHOFIELD ST
CURWENSVILLE PA
16833-1551
US

V. Phone/Fax

Practice location:
  • Phone: 814-393-2102
  • Fax:
Mailing address:
  • Phone: 814-553-1663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT007012
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: