Provider Demographics
NPI:1982972725
Name:HARRIS, TYNEISHA
Entity Type:Individual
Prefix:
First Name:TYNEISHA
Middle Name:
Last Name:HARRIS
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 1:4229 WALDROP HILLS TER
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6746
Mailing Address - Country:US
Mailing Address - Phone:404-343-3304
Mailing Address - Fax:404-549-3455
Practice Address - Street 1:544 MEDLOCK RD
Practice Address - Street 2:SUITE 106
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1515
Practice Address - Country:US
Practice Address - Phone:404-579-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006485101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor