Provider Demographics
NPI:1023726338
Name:WHITE, TIESHA M
Entity type:Individual
Prefix:
First Name:TIESHA
Middle Name:M
Last Name:WHITE
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 1:3720 FARRAGUT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3720 FARRAGUT AVE STE 109
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2110
Practice Address - Country:US
Practice Address - Phone:240-480-0741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR02194225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist