Provider Demographics
NPI:1720850597
Name:LITTLEJOHN, TYKEEBA M
Entity type:Individual
Prefix:
First Name:TYKEEBA
Middle Name:M
Last Name:LITTLEJOHN
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 1:2615 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-4733
Mailing Address - Country:US
Mailing Address - Phone:336-346-4666
Mailing Address - Fax:
Practice Address - Street 1:2313 ATLANTA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-4003
Practice Address - Country:US
Practice Address - Phone:336-346-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities