Provider Demographics
NPI:1366268351
Name:DARRISAW, TYNIKA (RBT)
Entity type:Individual
Prefix:
First Name:TYNIKA
Middle Name:
Last Name:DARRISAW
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 BOXWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4653
Mailing Address - Country:US
Mailing Address - Phone:706-641-9229
Mailing Address - Fax:
Practice Address - Street 1:347 BOXWOOD CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4653
Practice Address - Country:US
Practice Address - Phone:706-641-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB11848030106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician