Provider Demographics
NPI:1356830392
Name:SPORTS, NASASHA
Entity Type:Individual
Prefix:
First Name:NASASHA
Middle Name:
Last Name:SPORTS
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 1:12819 DAYBREAK CIR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9518
Mailing Address - Country:US
Mailing Address - Phone:757-696-2018
Mailing Address - Fax:
Practice Address - Street 1:145 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4014
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA61789270106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty