Provider Demographics
NPI:1083709554
Name:FLORA, TYSON RAE (MA LMHC)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:RAE
Last Name:FLORA
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 CONSTITUTION DR STE D
Mailing Address - Street 2:LIFEWORKS COUNSELING & CONSULTING, INC.
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1583
Mailing Address - Country:US
Mailing Address - Phone:260-432-0066
Mailing Address - Fax:260-432-8503
Practice Address - Street 1:6202 CONSTITUTION DR STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1583
Practice Address - Country:US
Practice Address - Phone:260-432-0066
Practice Address - Fax:260-432-8503
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001576A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200912670AMedicaid
IN39001576AOtherLICENSE NUMBER