Provider Demographics
NPI:1124364419
Name:TYISKA-JOHNSON, ANDRA L (MAPC, LLPC, CADC)
Entity Type:Individual
Prefix:MS
First Name:ANDRA
Middle Name:L
Last Name:TYISKA-JOHNSON
Suffix:
Gender:F
Credentials:MAPC, LLPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 SEYMOUR AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-4343
Mailing Address - Country:US
Mailing Address - Phone:810-931-8902
Mailing Address - Fax:810-233-9028
Practice Address - Street 1:4119 N SAGINAW ST
Practice Address - Street 2:SUITE 107
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-3995
Practice Address - Country:US
Practice Address - Phone:810-820-3432
Practice Address - Fax:810-820-3439
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010799101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional