Provider Demographics
NPI:1497502579
Name:SMITH, TISHARA TYAI
Entity type:Individual
Prefix:
First Name:TISHARA
Middle Name:TYAI
Last Name:SMITH
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:NEWPORT BEACH CA
Mailing Address - Street 2:1151 DOVE STREET
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26385 SANTA ROSA DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4215
Practice Address - Country:US
Practice Address - Phone:951-488-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician