Provider Demographics
NPI:1093429177
Name:SQUIRE, T'AISYA
Entity Type:Individual
Prefix:
First Name:T'AISYA
Middle Name:
Last Name:SQUIRE
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 1:6228 RIVENDELL CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-4795
Mailing Address - Country:US
Mailing Address - Phone:804-539-6662
Mailing Address - Fax:
Practice Address - Street 1:306 TURNER RD STE L-M
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-6432
Practice Address - Country:US
Practice Address - Phone:804-477-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060133631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical