Provider Demographics
NPI:1588315915
Name:LASHLEY, TIARA ISIS
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:ISIS
Last Name:LASHLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 BROADWAY ST STE 301
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-7331
Mailing Address - Country:US
Mailing Address - Phone:573-507-3715
Mailing Address - Fax:
Practice Address - Street 1:338 BROADWAY ST STE 301
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7331
Practice Address - Country:US
Practice Address - Phone:573-507-3715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-21-189889106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician