Provider Demographics
NPI:1508820895
Name:ESHAM, TYHANNA D (OT)
Entity Type:Individual
Prefix:
First Name:TYHANNA
Middle Name:D
Last Name:ESHAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3385
Mailing Address - Country:US
Mailing Address - Phone:678-985-7190
Mailing Address - Fax:678-985-7158
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3385
Practice Address - Country:US
Practice Address - Phone:678-985-7190
Practice Address - Fax:678-985-7158
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBLSMedicare ID - Type Unspecified
GAQ35495Medicare UPIN