Provider Demographics
NPI:1477213908
Name:ROYAL, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:ROYAL
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 1:105 ROYALS RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-6311
Mailing Address - Country:US
Mailing Address - Phone:229-415-4344
Mailing Address - Fax:
Practice Address - Street 1:2704 N OAK ST BLDG A1
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5901
Practice Address - Country:US
Practice Address - Phone:229-474-4384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-24
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-197792106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician