Provider Demographics
NPI:1508589318
Name:FORBES, TANISHA
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:FORBES
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 1:3824 CRIMSON CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7453
Mailing Address - Country:US
Mailing Address - Phone:215-909-2639
Mailing Address - Fax:
Practice Address - Street 1:6239 EDGEWATER DR STE N4
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:FL
Practice Address - Zip Code:32810-4736
Practice Address - Country:US
Practice Address - Phone:407-900-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VIRBT-21-164233106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty