Provider Demographics
NPI:1134802630
Name:TYES, KEONTRA
Entity type:Individual
Prefix:
First Name:KEONTRA
Middle Name:
Last Name:TYES
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 1:484 IRVIN CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-5406
Mailing Address - Country:US
Mailing Address - Phone:404-297-4248
Mailing Address - Fax:
Practice Address - Street 1:484 IRVIN CT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-5406
Practice Address - Country:US
Practice Address - Phone:404-297-4248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD004381231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist