Provider Demographics
NPI:1740599901
Name:COLEMAN, TYISHA DEANNE (MA60182845)
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:DEANNE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MA60182845
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 S 360TH ST
Mailing Address - Street 2:F 307
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-7162
Mailing Address - Country:US
Mailing Address - Phone:206-940-5822
Mailing Address - Fax:
Practice Address - Street 1:2020 S 360TH ST
Practice Address - Street 2:F 307
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7162
Practice Address - Country:US
Practice Address - Phone:206-940-5822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60182845225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60182845OtherMASSAGE LICENSE