Provider Demographics
NPI:1285458968
Name:MCCORD, TYLIYAH
Entity type:Individual
Prefix:
First Name:TYLIYAH
Middle Name:
Last Name:MCCORD
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:PO BOX 931142
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3830 WASHINGTON RD STE 2
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5065
Practice Address - Country:US
Practice Address - Phone:762-222-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-379583106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician