Provider Demographics
NPI:1396368288
Name:GHOLSON, TISHA L
Entity Type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:L
Last Name:GHOLSON
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 1:4600 WINTERBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-1727
Mailing Address - Country:US
Mailing Address - Phone:804-299-0058
Mailing Address - Fax:
Practice Address - Street 1:4600 WINTERBOURNE DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23803-1727
Practice Address - Country:US
Practice Address - Phone:804-299-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care