Provider Demographics
NPI:1609408798
Name:SMITH, TYISHA (LMT)
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7806 BEECHNUT RD
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-4730
Mailing Address - Country:US
Mailing Address - Phone:202-642-7708
Mailing Address - Fax:
Practice Address - Street 1:7806 BEECHNUT RD
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4730
Practice Address - Country:US
Practice Address - Phone:202-642-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist