Healthcare Provider Details

I. General information

NPI: 1558227918
Provider Name (Legal Business Name): TACIDY WILLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE CT
POOLER GA
31322-9445
US

IV. Provider business mailing address

100 HARLEY LN APT 1401
POOLER GA
31322-3953
US

V. Phone/Fax

Practice location:
  • Phone: 615-560-6622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-493740
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: