Provider Demographics
NPI:1346798410
Name:TYSON, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:20620 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:MI
Mailing Address - Zip Code:49338-9708
Mailing Address - Country:US
Mailing Address - Phone:231-679-6588
Mailing Address - Fax:
Practice Address - Street 1:4473 220TH AVE
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-8593
Practice Address - Country:US
Practice Address - Phone:231-832-2247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401-015667101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health