Provider Demographics
NPI:1912791559
Name:SHADDI, TYESHA
Entity type:Individual
Prefix:
First Name:TYESHA
Middle Name:
Last Name:SHADDI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 AVOCET SEA LN
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4252
Mailing Address - Country:US
Mailing Address - Phone:770-685-8233
Mailing Address - Fax:
Practice Address - Street 1:417 AVOCET SEA LN
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4252
Practice Address - Country:US
Practice Address - Phone:770-685-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist