Provider Demographics
NPI:1861912164
Name:MCKISSACK, TASHA MARIE
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:MARIE
Last Name:MCKISSACK
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 1:1492 S SILICON WAY STE A
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7156
Mailing Address - Country:US
Mailing Address - Phone:435-275-8911
Mailing Address - Fax:435-200-9442
Practice Address - Street 1:1492 S SILICON WAY STE A
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-275-8911
Practice Address - Fax:435-200-9442
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13276557-2506103K00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst