=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982218087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIARA BRADLEY MASSAGE THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2020
-----------------------------------------------------
Last Update Date | 12/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 PACES RDG APT A
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-471-2183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2305 HERITAGE GREEN TRL
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-471-2183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT011663
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------