Provider Demographics
NPI:1164769261
Name:TYSON, KELLY SEGRAVES (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SEGRAVES
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 1:3913 GRIESE LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-8301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3913 GRIESE LN
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-8301
Practice Address - Country:US
Practice Address - Phone:706-877-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003687101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health