Provider Demographics
NPI:1013523042
Name:NORMAN, THIACE AYESHA MARIE
Entity type:Individual
Prefix:
First Name:THIACE
Middle Name:AYESHA MARIE
Last Name:NORMAN
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 1:23 MILLHOLLAND DR W
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1523
Mailing Address - Country:US
Mailing Address - Phone:917-557-4842
Mailing Address - Fax:
Practice Address - Street 1:23 MILLHOLLAND DR W
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1523
Practice Address - Country:US
Practice Address - Phone:917-557-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist