Provider Demographics
NPI:1609408798
Name:SMITH, TYISHA (LMT)
Entity type:Individual
Prefix:
First Name:TYISHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 RIDING CROP WAY
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1286
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13975 CONNECTICUT AVE STE 250
Practice Address - Street 2:
Practice Address - City:ASPEN HILL
Practice Address - State:MD
Practice Address - Zip Code:20906-2900
Practice Address - Country:US
Practice Address - Phone:240-730-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist