Provider Demographics
NPI:1164010179
Name:LAWSON, TYAHANNA
Entity Type:Individual
Prefix:
First Name:TYAHANNA
Middle Name:
Last Name:LAWSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1358
Mailing Address - Country:US
Mailing Address - Phone:302-212-7091
Mailing Address - Fax:
Practice Address - Street 1:617 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1358
Practice Address - Country:US
Practice Address - Phone:302-212-7091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-21-150101106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD523411500Medicaid