Healthcare Provider Details

I. General information

NPI: 1457968729
Provider Name (Legal Business Name): TASHAI SHELBY BRANTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 HOWELL FERRY RD STE 400
DULUTH GA
30096-3186
US

IV. Provider business mailing address

3655 HOWELL FERRY RD STE 400
DULUTH GA
30096-3186
US

V. Phone/Fax

Practice location:
  • Phone: 770-373-5822
  • Fax: 248-712-4381
Mailing address:
  • Phone: 770-373-5822
  • Fax: 248-712-4381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: