=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619609310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIARA BRACEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2022
-----------------------------------------------------
Last Update Date | 06/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6071 HIGHWAY 85 APT 31A
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-437-7350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6691 CHURCH ST UNIT 960843
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30296-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-437-7350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 000000
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------