Provider Demographics
NPI:1851034326
Name:PHILLIPS, TANISHA MARIE (RBT)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:MARIE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:703 GODWIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-4009
Mailing Address - Country:US
Mailing Address - Phone:757-227-7708
Mailing Address - Fax:
Practice Address - Street 1:703 GODWIN ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-4009
Practice Address - Country:US
Practice Address - Phone:757-227-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA15270170103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15270170Medicaid