Provider Demographics
NPI:1922270941
Name:SEABOROUGH, TYNEISE
Entity Type:Individual
Prefix:
First Name:TYNEISE
Middle Name:
Last Name:SEABOROUGH
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 1:508 ATKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-1830
Mailing Address - Country:US
Mailing Address - Phone:912-401-4105
Mailing Address - Fax:912-257-7616
Practice Address - Street 1:508 ATKINSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-401-4105
Practice Address - Fax:912-257-7616
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC010000490225X00000X
GAOT004867225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132673AMedicaid