Provider Demographics
NPI:1891685152
Name:TYLER, WILLIE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:TYLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 ROSWELL RD # APTW12
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5814
Mailing Address - Country:US
Mailing Address - Phone:470-602-1966
Mailing Address - Fax:
Practice Address - Street 1:5555 ROSWELL RD # APTW12
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5814
Practice Address - Country:US
Practice Address - Phone:470-602-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 311ZA0620X
GA175T00000X, 225800000X, 253Z00000X, 347C00000X, 347E00000X, 372600000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171400000XOther Service ProvidersHealth & Wellness Coach
No175T00000XOther Service ProvidersPeer Specialist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No253Z00000XAgenciesIn Home Supportive Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker
No372600000XNursing Service Related ProvidersAdult Companion