Provider Demographics
NPI:1912348343
Name:BRACEY, TANISHA S
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:S
Last Name:BRACEY
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 1:5403 CABOT RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3214
Mailing Address - Country:US
Mailing Address - Phone:202-277-9687
Mailing Address - Fax:703-250-3782
Practice Address - Street 1:5403 CABOT RIDGE CT
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-3214
Practice Address - Country:US
Practice Address - Phone:202-277-9687
Practice Address - Fax:703-250-3782
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical