Provider Demographics
NPI:1245958644
Name:NEDD, TYISHA D (DMT-LP)
Entity type:Individual
Prefix:
First Name:TYISHA
Middle Name:D
Last Name:NEDD
Suffix:
Gender:F
Credentials:DMT-LP
Other - Prefix:
Other - First Name:TYISHA
Other - Middle Name:D
Other - Last Name:NEDD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1282 BUSHWICK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2295
Mailing Address - Country:US
Mailing Address - Phone:614-360-8281
Mailing Address - Fax:
Practice Address - Street 1:1282 BUSHWICK AVE APT 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2295
Practice Address - Country:US
Practice Address - Phone:614-360-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP113472225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist