Provider Demographics
NPI:1447505078
Name:REAVES, TASHAWA
Entity type:Individual
Prefix:
First Name:TASHAWA
Middle Name:
Last Name:REAVES
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 1:3920 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-3008
Mailing Address - Country:US
Mailing Address - Phone:734-834-9676
Mailing Address - Fax:313-355-9141
Practice Address - Street 1:3920 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-3008
Practice Address - Country:US
Practice Address - Phone:734-834-9676
Practice Address - Fax:313-355-9141
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist