Provider Demographics
NPI:1366903494
Name:LEVERETT, TIA S (LM, CPM)
Entity type:Individual
Prefix:MS
First Name:TIA
Middle Name:S
Last Name:LEVERETT
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 GAZETTA WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-1057
Mailing Address - Country:US
Mailing Address - Phone:561-635-4497
Mailing Address - Fax:
Practice Address - Street 1:2316 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6703
Practice Address - Country:US
Practice Address - Phone:954-925-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW377176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife