Provider Demographics
NPI:1407043763
Name:BEATON, TISHA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:
Last Name:BEATON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 GIBSON CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-6252
Mailing Address - Country:US
Mailing Address - Phone:731-697-8118
Mailing Address - Fax:
Practice Address - Street 1:219 GIBSON CEMETERY RD
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-6252
Practice Address - Country:US
Practice Address - Phone:731-697-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2570225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant