Provider Demographics
NPI:1043981962
Name:CARROLL, TANISHA NICOLE KINI
Entity Type:Individual
Prefix:MRS
First Name:TANISHA
Middle Name:NICOLE KINI
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:NICOLE KINI
Other - Last Name:LEAVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 MOSSY OAK LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-1236
Mailing Address - Country:US
Mailing Address - Phone:678-794-5578
Mailing Address - Fax:678-742-8553
Practice Address - Street 1:80 MOSSY OAK LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1236
Practice Address - Country:US
Practice Address - Phone:678-794-5578
Practice Address - Fax:678-742-8553
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician