Healthcare Provider Details

I. General information

NPI: 1639009434
Provider Name (Legal Business Name): TYSHAWN MITCHELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 SHACKLEFORD RD APT 548
DULUTH GA
30096-8341
US

IV. Provider business mailing address

2221 PEACHTREE RD NE STE 6
ATLANTA GA
30309-1148
US

V. Phone/Fax

Practice location:
  • Phone: 737-808-1457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015698
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: