Provider Demographics
NPI:1609479625
Name:OSBORNE, TANYETTA NICOLE
Entity Type:Individual
Prefix:
First Name:TANYETTA
Middle Name:NICOLE
Last Name:OSBORNE
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 1:6939 BEAVER TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1929
Mailing Address - Country:US
Mailing Address - Phone:706-326-2571
Mailing Address - Fax:
Practice Address - Street 1:3100 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1890
Practice Address - Country:US
Practice Address - Phone:470-485-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-144795106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician