Provider Demographics
NPI:1447769534
Name:TYRE, KHALILAH IMANI
Entity Type:Individual
Prefix:MS
First Name:KHALILAH
Middle Name:IMANI
Last Name:TYRE
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 1:211 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-5410
Mailing Address - Country:US
Mailing Address - Phone:646-250-3643
Mailing Address - Fax:
Practice Address - Street 1:22 PLEASANT ST STE 2000
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5119
Practice Address - Country:US
Practice Address - Phone:781-851-2648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health