MEDICARE: TIERRA PETRUS

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

General Provider Information

NPI Number	:	1265110589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIERRA PETRUS

Provider Business Mailing Address
First Line	:	6416 ROBERT DR
Second Line	:
City	:	SOUTH EASTON
State	:	MA
Zip	:	02375-1837
Country	:	US
Telephone Number	:	781-664-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6416 ROBERT DR
Second Line	:
City	:	SOUTH EASTON
State	:	MA
Zip	:	02375-1837
Country	:	US
Telephone Number	:	781-664-3400
Fax Number	:

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

Provider Enumeration Date	:	07/06/2023
Last Update Date	:	07/06/2023

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Directions to “ TIERRA PETRUS ” Practice Location

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