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General NPI Number Information
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NPI Number | 1841683737
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Entity Type | Individual
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Provider Name | TYNEISHA DONISHA DOUGLAS CLINICAL SOCIAL WORK
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Gender | Female
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Dates
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Enumeration Date | 03/17/2015
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Last Update Date | 08/25/2023
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Provider Practice Location Address
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Address Line | 2274 SALEM ROAD SE SUITE 106
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City | CONYERS
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State | GA
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Zip | 30013
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Country | US
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Telephone | 404-631-7716
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Fax |
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Provider Business Mailing Address
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Address Line | 2274 SALEM RD SE STE 106-1409
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City | CONYERS
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State | GA
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Zip | 30013-2097
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Country | US
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Telephone | 470-331-4654
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Fax | 404-745-0807
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC200002835
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | TPSW1094
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW007607
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License Number State | GA
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