Provider Demographics
NPI:1326536376
Name:ANDERSON, TYRONE
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1031
Mailing Address - Country:US
Mailing Address - Phone:773-777-7112
Mailing Address - Fax:773-887-3300
Practice Address - Street 1:5910 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-1031
Practice Address - Country:US
Practice Address - Phone:773-777-7112
Practice Address - Fax:773-887-3300
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11457101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-3297629Medicaid