Healthcare Provider Details

I. General information

NPI: 1891685152
Provider Name (Legal Business Name): WILLIE TYLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 ROSWELL RD # APTW12
ATLANTA GA
30342-5814
US

IV. Provider business mailing address

5555 ROSWELL RD # APTW12
ATLANTA GA
30342-5814
US

V. Phone/Fax

Practice location:
  • Phone: 470-602-1966
  • Fax:
Mailing address:
  • Phone: 470-602-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateGA
# 9
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: