1124251590 NPI number — TANYA THERIOT, PSY.D., P.C.

Table of content: (NPI 1124251590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124251590 NPI number — TANYA THERIOT, PSY.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TANYA THERIOT, PSY.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124251590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 724384
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31139-1384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-310-1792
Provider Business Mailing Address Fax Number:
404-945-1211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 ROSWELL RD
Provider Second Line Business Practice Location Address:
SUITE 185
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-310-1792
Provider Business Practice Location Address Fax Number:
770-945-1211
Provider Enumeration Date:
09/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
THERIOT
Authorized Official First Name:
TANYA
Authorized Official Middle Name:
SAPORITA
Authorized Official Title or Position:
OWNER, CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
770-310-1792

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY002887 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 409047010A , issued by the state of ( GU ) . This identifiers is of the category "MEDICAID".




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