Healthcare Provider Details

I. General information

NPI: 1730005315
Provider Name (Legal Business Name): TYRREN D HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE CT POOLER
POOLER GA
31322
US

IV. Provider business mailing address

2 ADDISON PL # 8205
POOLER GA
31322-4177
US

V. Phone/Fax

Practice location:
  • Phone: 615-560-6622
  • Fax:
Mailing address:
  • Phone: 912-604-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number26-528302
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: