Provider Demographics
NPI:1154868065
Name:KIRA, TAISSA (MAC, LAC)
Entity type:Individual
Prefix:
First Name:TAISSA
Middle Name:
Last Name:KIRA
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ALDERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2247
Mailing Address - Country:US
Mailing Address - Phone:484-367-5077
Mailing Address - Fax:
Practice Address - Street 1:405 ALDERBROOK DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2247
Practice Address - Country:US
Practice Address - Phone:484-367-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001205171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist