Provider Demographics
NPI:1063994218
Name:FRAZER-NEW, TYSHAWNA
Entity type:Individual
Prefix:
First Name:TYSHAWNA
Middle Name:
Last Name:FRAZER-NEW
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 1:2320 LAGUNA CT UNIT 206
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-1139
Mailing Address - Country:US
Mailing Address - Phone:937-532-8624
Mailing Address - Fax:
Practice Address - Street 1:2320 LAGUNA CT UNIT 206
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-1139
Practice Address - Country:US
Practice Address - Phone:937-532-8624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool