Provider Demographics
NPI:1710877295
Name:RUTHERFORD, TYANNA TELLICE
Entity type:Individual
Prefix:
First Name:TYANNA
Middle Name:TELLICE
Last Name:RUTHERFORD
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 1:38647 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-4746
Mailing Address - Country:US
Mailing Address - Phone:313-693-0709
Mailing Address - Fax:
Practice Address - Street 1:38647 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-4746
Practice Address - Country:US
Practice Address - Phone:313-693-0709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician