Provider Demographics
NPI:1134859705
Name:TARIQ, AYSHA
Entity type:Individual
Prefix:MISS
First Name:AYSHA
Middle Name:
Last Name:TARIQ
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 1:5154 VEACH RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-9419
Mailing Address - Country:US
Mailing Address - Phone:127-031-5248
Mailing Address - Fax:
Practice Address - Street 1:8134 NEW LAGRANGE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4022
Practice Address - Country:US
Practice Address - Phone:502-472-7293
Practice Address - Fax:502-690-4500
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty