Healthcare Provider Details

I. General information

NPI: 1811573314
Provider Name (Legal Business Name): TYRONE MAURICE CAVE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GEORGIA AVE SE STE 206
ATLANTA GA
30312-3000
US

IV. Provider business mailing address

325 FAULKNER ST
STOCKBRIDGE GA
30281-2819
US

V. Phone/Fax

Practice location:
  • Phone: 757-692-0366
  • Fax:
Mailing address:
  • Phone: 757-692-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103146
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number1230989815
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number315103
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2095
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: