Healthcare Provider Details

I. General information

NPI: 1306221601
Provider Name (Legal Business Name): SHARON TYRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3387 THAMES PL
HEPHZIBAH GA
30815-7167
US

IV. Provider business mailing address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

V. Phone/Fax

Practice location:
  • Phone: 706-284-7810
  • Fax:
Mailing address:
  • Phone: 706-432-7893
  • Fax: 706-432-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: