Provider Demographics
NPI:1821163874
Name:THERIOT, TANYA SAPORITA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:SAPORITA
Last Name:THERIOT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TANYA
Other - Middle Name:SAPORITA
Other - Last Name:THERIOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 724384
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-1384
Mailing Address - Country:US
Mailing Address - Phone:770-310-1792
Mailing Address - Fax:404-943-1211
Practice Address - Street 1:3901 ROSWELL RD
Practice Address - Street 2:SUITE 217
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8809
Practice Address - Country:US
Practice Address - Phone:770-310-1792
Practice Address - Fax:404-943-1211
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA409047010AMedicaid