Provider Demographics
NPI:1386890796
Name:AUTRY, TIARA C
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:C
Last Name:AUTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIARA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:632 DEERING DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-5741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2295 W MARKET ST STE J
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-6944
Practice Address - Country:US
Practice Address - Phone:330-614-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
S.2005377104100000X
OHS.2005377104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor