Healthcare Provider Details

I. General information

NPI: 1316318827
Provider Name (Legal Business Name): TORDELLIE HUTCHINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NORTHSIDE DR NW
ATLANTA GA
30318-2673
US

IV. Provider business mailing address

336 OTHELLO DR
HAMPTON GA
30228-4831
US

V. Phone/Fax

Practice location:
  • Phone: 312-972-7868
  • Fax:
Mailing address:
  • Phone: 561-301-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-81528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: