Provider Demographics
NPI:1497265839
Name:DAVIS, TANISHA SHANELLE (PTA, LMBT)
Entity type:Individual
Prefix:MRS
First Name:TANISHA
Middle Name:SHANELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 BONITA CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1722
Mailing Address - Country:US
Mailing Address - Phone:910-929-4488
Mailing Address - Fax:
Practice Address - Street 1:823 ELM ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4172
Practice Address - Country:US
Practice Address - Phone:910-929-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5872225200000X
NC22449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant