Provider Demographics
NPI:1275961245
Name:TYSON, LAURA A (MSW LCSW LCADC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:TYSON
Suffix:
Gender:F
Credentials:MSW LCSW LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JOHNSON DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1124
Mailing Address - Country:US
Mailing Address - Phone:917-340-5203
Mailing Address - Fax:
Practice Address - Street 1:450 SPRINGFIELD AVE STE 302
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2611
Practice Address - Country:US
Practice Address - Phone:917-994-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NJ1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)