Provider Demographics
NPI:1225341670
Name:TYSON, KATELIN E
Entity Type:Individual
Prefix:MS
First Name:KATELIN
Middle Name:E
Last Name:TYSON
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 1:3671 BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-2197
Mailing Address - Country:US
Mailing Address - Phone:916-889-6805
Mailing Address - Fax:916-734-5520
Practice Address - Street 1:3671 BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-2197
Practice Address - Country:US
Practice Address - Phone:916-889-6805
Practice Address - Fax:916-734-5520
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist