Provider Demographics
NPI:1265021208
Name:TYREE, TERESSA HAIRSTON
Entity Type:Individual
Prefix:
First Name:TERESSA
Middle Name:HAIRSTON
Last Name:TYREE
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 1:190 BRASS SHOP RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-3355
Mailing Address - Country:US
Mailing Address - Phone:276-732-4324
Mailing Address - Fax:276-226-1070
Practice Address - Street 1:603 STARLING AVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4221
Practice Address - Country:US
Practice Address - Phone:276-732-4324
Practice Address - Fax:276-226-1070
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010380101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional