Provider Demographics
NPI:1053760298
Name:DELOATCH, TIA MONIQUE
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:MONIQUE
Last Name:DELOATCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:MONIQUE
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5615 S PECOS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1961
Mailing Address - Country:US
Mailing Address - Phone:702-736-8100
Mailing Address - Fax:
Practice Address - Street 1:5615 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1961
Practice Address - Country:US
Practice Address - Phone:702-736-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner