Provider Demographics
NPI:1457850745
Name:TYSON, MARYJO
Entity Type:Individual
Prefix:
First Name:MARYJO
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 1:12465 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3041
Mailing Address - Country:US
Mailing Address - Phone:757-886-7744
Mailing Address - Fax:757-989-0231
Practice Address - Street 1:13460 WOODSIDE LN
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-1364
Practice Address - Country:US
Practice Address - Phone:757-886-7744
Practice Address - Fax:757-989-0231
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0605142103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool