Provider Demographics
NPI:1720829054
Name:HAMILTON, TENNILLE
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:
Last Name:HAMILTON
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 1:210 BOBBIE ST
Mailing Address - Street 2:
Mailing Address - City:ALLENHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31301-2661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 BOBBIE ST
Practice Address - Street 2:
Practice Address - City:ALLENHURST
Practice Address - State:GA
Practice Address - Zip Code:31301-2661
Practice Address - Country:US
Practice Address - Phone:912-385-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional