Healthcare Provider Details

I. General information

NPI: 1366097776
Provider Name (Legal Business Name): SIMIKO STEWART-TIANYVU LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 08/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WAVERLY LN
RICHMOND HILL GA
31324-7805
US

IV. Provider business mailing address

61 WAVERLY LN
RICHMOND HILL GA
31324-7805
US

V. Phone/Fax

Practice location:
  • Phone: 912-675-4256
  • Fax:
Mailing address:
  • Phone: 404-312-1522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC0190
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number007667
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: