Provider Demographics
NPI:1255046322
Name:TAYLOR, TISHA (LMT)
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:TAYLOR
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 1:5301 S BODINE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1409
Mailing Address - Country:US
Mailing Address - Phone:409-449-1841
Mailing Address - Fax:
Practice Address - Street 1:5301 S BODINE DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-1409
Practice Address - Country:US
Practice Address - Phone:409-449-1841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK173237225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist