1073139317 NPI number — TYISHA SALTER SCOTT M.ED

Table of content: TYISHA SALTER SCOTT M.ED (NPI 1073139317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073139317 NPI number — TYISHA SALTER SCOTT M.ED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
TYISHA
Provider Middle Name:
SALTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073139317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8078 SUNBURST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30296-3439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-379-9846
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 HABERSHAM DRIVE
Provider Second Line Business Practice Location Address:
SUITE 142
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-371-5057
Provider Business Practice Location Address Fax Number:
404-537-1045
Provider Enumeration Date:
06/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC014397 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com