Provider Demographics
NPI:1477199479
Name:ANYANWU-TYSON, SOPHIA (DPT)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:
Last Name:ANYANWU-TYSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 SNAPFINGER PARK DR STE 130
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4066
Mailing Address - Country:US
Mailing Address - Phone:770-322-7003
Mailing Address - Fax:
Practice Address - Street 1:5255 SNAPFINGER PARK DR STE 130
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4066
Practice Address - Country:US
Practice Address - Phone:770-322-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist