Provider Demographics
NPI:1093324881
Name:COATES, TISCHA ELAINE
Entity Type:Individual
Prefix:
First Name:TISCHA
Middle Name:ELAINE
Last Name:COATES
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 1:4661 MERRICK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3354
Mailing Address - Country:US
Mailing Address - Phone:937-245-2642
Mailing Address - Fax:937-278-9418
Practice Address - Street 1:4661 MERRICK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3354
Practice Address - Country:US
Practice Address - Phone:937-245-2642
Practice Address - Fax:937-278-9418
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251X00000X, 372500000X, 376J00000X, 385HR2060X, 3747P1801X
385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No251X00000XAgenciesSupports Brokerage
No372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241240Medicaid