Provider Demographics
NPI:1841474491
Name:POWELL, TYSHA MOANA (AUD)
Entity type:Individual
Prefix:DR
First Name:TYSHA
Middle Name:MOANA
Last Name:POWELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 WAVERTREE RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4251
Mailing Address - Country:US
Mailing Address - Phone:404-484-6305
Mailing Address - Fax:
Practice Address - Street 1:5001 SPRING VALLEY RD
Practice Address - Street 2:SUITE 400E
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3946
Practice Address - Country:US
Practice Address - Phone:972-383-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003621231H00000X
TX80517231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist