MEDICARE: MRS. SIMIKO STEWART-TIANYVU LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	C0190	GA
2	101YP2500X	Professional Counselor	007667	GA

General Provider Information

NPI Number	:	1366097776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SIMIKO STEWART-TIANYVU LPC

Provider Business Mailing Address
First Line	:	61 WAVERLY LN
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-7805
Country	:	US
Telephone Number	:	404-312-1522
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 WAVERLY LN
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-7805
Country	:	US
Telephone Number	:	912-675-4256
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2019
Last Update Date	:	08/03/2019

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