Provider Demographics
NPI:1063288116
Name:BENNY, TIYARA
Entity type:Individual
Prefix:
First Name:TIYARA
Middle Name:
Last Name:BENNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1482 GREAT SHOALS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7088
Mailing Address - Country:US
Mailing Address - Phone:404-709-1225
Mailing Address - Fax:
Practice Address - Street 1:13128 TOTEM LAKE BLVD NE STE 204
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2953
Practice Address - Country:US
Practice Address - Phone:425-820-8474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist