Provider Demographics
NPI:1114498276
Name:TYSON, MELINDA K (MS)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:K
Last Name:TYSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 VILLA RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3009
Mailing Address - Country:US
Mailing Address - Phone:864-283-0637
Mailing Address - Fax:864-283-0638
Practice Address - Street 1:17 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4407
Practice Address - Country:US
Practice Address - Phone:864-283-0637
Practice Address - Fax:864-283-0638
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health