Provider Demographics
NPI:1841683737
Name:DOUGLAS, TYNEISHA DONISHA (CLINICAL SOCIAL WORK)
Entity type:Individual
Prefix:
First Name:TYNEISHA
Middle Name:DONISHA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:TYNEISHA
Other - Middle Name:DONISHA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CLINICAL SOCIAL WORK
Mailing Address - Street 1:2274 SALEM RD SE STE 106-1409
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2097
Mailing Address - Country:US
Mailing Address - Phone:470-331-4654
Mailing Address - Fax:404-745-0807
Practice Address - Street 1:2274 SALEM ROAD SE
Practice Address - Street 2:SUITE 106
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:404-631-7716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC2000028351041C0700X
FLTPSW10941041C0700X
GACSW0076071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical