Provider Demographics
NPI:1861176372
Name:CANADA, TYNIA
Entity type:Individual
Prefix:
First Name:TYNIA
Middle Name:
Last Name:CANADA
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 1:1750 POWER SPRINGS RD. SW
Mailing Address - Street 2:SUITE 190-101
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:410-564-7545
Mailing Address - Fax:
Practice Address - Street 1:1750 POWER SPRINGS RD. SW
Practice Address - Street 2:SUITE 190-101
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:410-564-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGO122101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health