Provider Demographics
NPI:1073383527
Name:ANDERSON, TYRIQUE
Entity Type:Individual
Prefix:
First Name:TYRIQUE
Middle Name:
Last Name:ANDERSON
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 1:4654 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44864-9694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 N WATER ST
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-1250
Practice Address - Country:US
Practice Address - Phone:567-560-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305220-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health