Provider Demographics
NPI:1407386121
Name:TYUS, THOMAS SHANE (CDCA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:SHANE
Last Name:TYUS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 GENOA AVE SW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-9425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6694 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OH
Practice Address - Zip Code:44216-9201
Practice Address - Country:US
Practice Address - Phone:330-825-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)