Provider Demographics
NPI:1508651779
Name:BRYDIE, TANISHA
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:BRYDIE
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 1:18120 66TH CT
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6403
Mailing Address - Country:US
Mailing Address - Phone:708-513-2633
Mailing Address - Fax:
Practice Address - Street 1:18120 66TH CT
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6403
Practice Address - Country:US
Practice Address - Phone:708-513-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician