Healthcare Provider Details

I. General information

NPI: 1386558245
Provider Name (Legal Business Name): SAMUEL YAMA EMILE TONDREAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 JIMMIE DYESS PKWY
AUGUSTA GA
30909-9469
US

IV. Provider business mailing address

1113 HUNTINGTON DR
AUGUSTA GA
30909-4589
US

V. Phone/Fax

Practice location:
  • Phone: 706-640-5832
  • Fax:
Mailing address:
  • Phone: 912-358-6850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2854859
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: