Provider Demographics
NPI:1275051617
Name:STREETER, TASHAE (ASSOCIATES OF SCIENC)
Entity Type:Individual
Prefix:
First Name:TASHAE
Middle Name:
Last Name:STREETER
Suffix:
Gender:F
Credentials:ASSOCIATES OF SCIENC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 WARM SPRINGS RD APT K6
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-9165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4411 ROSEMONT DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5634
Practice Address - Country:US
Practice Address - Phone:706-327-0279
Practice Address - Fax:706-327-5294
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1154315422Medicaid