Provider Demographics
NPI:1164101218
Name:TYSON, CANDICE LILLIAN (LGPC)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LILLIAN
Last Name:TYSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 SMITH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3796
Mailing Address - Country:US
Mailing Address - Phone:410-779-1314
Mailing Address - Fax:410-779-1336
Practice Address - Street 1:1340 SMITH AVE STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3796
Practice Address - Country:US
Practice Address - Phone:410-779-1314
Practice Address - Fax:410-779-1336
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13892101Y00000X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor