Healthcare Provider Details

I. General information

NPI: 1396544946
Provider Name (Legal Business Name): TYLISAEA BONNER DSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 TALON DE SE
RYDAL GA
30171
US

IV. Provider business mailing address

156 TALON DR SE
RYDAL GA
30171-1787
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-7204
  • Fax:
Mailing address:
  • Phone: 404-851-7204
  • Fax: 404-601-9692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW010655
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: