Provider Demographics
NPI:1083118582
Name:TYRELL, S VALENCIA (CPC)
Entity Type:Individual
Prefix:
First Name:S VALENCIA
Middle Name:
Last Name:TYRELL
Suffix:
Gender:F
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CAPITOL HEIGHTS BLVD
Mailing Address - Street 2:SUITE #B
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743
Mailing Address - Country:US
Mailing Address - Phone:240-505-8960
Mailing Address - Fax:240-505-8960
Practice Address - Street 1:920 CAPITOL HEIGHTS BLVD
Practice Address - Street 2:SUITE #B
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743
Practice Address - Country:US
Practice Address - Phone:240-505-8960
Practice Address - Fax:240-505-8960
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD077348897405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD462409305OtherCIGNA, UHC, CAREFIRST, AETNA, MEDICAID