MEDICARE: TIAYRA SHANI BRANCH RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		TN

General Provider Information

NPI Number	:	1023693900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIAYRA SHANI BRANCH RBT

Provider Business Mailing Address
First Line	:	3520 HECKLE AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38111-5104
Country	:	US
Telephone Number	:	901-679-2641
Fax Number	:

Provider Business Practice Location Address
First Line	:	146 TIMBER CREEK DR
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4395
Country	:	US
Telephone Number	:	901-249-7838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2021
Last Update Date	:	03/12/2021

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