Provider Demographics
NPI:1417205774
Name:DAVIS, TYSON
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:DAVIS
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 1:1515 S CAPITAL OF TEXAS HWY
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6544
Mailing Address - Country:US
Mailing Address - Phone:512-767-1136
Mailing Address - Fax:
Practice Address - Street 1:1515 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:STE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6544
Practice Address - Country:US
Practice Address - Phone:512-767-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38201103TC0700X
PAPS017720103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty