Provider Demographics
NPI:1821711755
Name:COLLINS, TANISHA (LMT)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:COLLINS
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 1:6230 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2249
Mailing Address - Country:US
Mailing Address - Phone:470-782-2440
Mailing Address - Fax:
Practice Address - Street 1:6230 MELROSE ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2249
Practice Address - Country:US
Practice Address - Phone:470-782-2440
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
GAMT013607225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist