Provider Demographics
NPI:1124251590
Name:TANYA THERIOT, PSY.D., P.C.
Entity type:Organization
Organization Name:TANYA THERIOT, PSY.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:SAPORITA
Authorized Official - Last Name:THERIOT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-310-1792
Mailing Address - Street 1:PO BOX 724384
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-1384
Mailing Address - Country:US
Mailing Address - Phone:770-310-1792
Mailing Address - Fax:404-945-1211
Practice Address - Street 1:3939 ROSWELL RD
Practice Address - Street 2:SUITE 185
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6251
Practice Address - Country:US
Practice Address - Phone:770-310-1792
Practice Address - Fax:770-945-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU409047010AMedicaid