Provider Demographics
NPI:1164064044
Name:TYSON, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331271
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06133-1271
Mailing Address - Country:US
Mailing Address - Phone:860-778-9078
Mailing Address - Fax:
Practice Address - Street 1:330 MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1851
Practice Address - Country:US
Practice Address - Phone:860-778-9078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1329101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1329Medicaid