Provider Demographics
NPI:1679603815
Name:CANZONERI, TERE TYNER (MDIV, MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TERE
Middle Name:TYNER
Last Name:CANZONERI
Suffix:
Gender:F
Credentials:MDIV, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1843
Mailing Address - Country:US
Mailing Address - Phone:404-664-6254
Mailing Address - Fax:404-634-0505
Practice Address - Street 1:1790 LAVISTA RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3604
Practice Address - Country:US
Practice Address - Phone:404-664-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical