Provider Demographics
NPI:1528582830
Name:MACDONALD, TYLICE C
Entity Type:Individual
Prefix:
First Name:TYLICE
Middle Name:C
Last Name:MACDONALD
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 1:170 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2901
Mailing Address - Country:US
Mailing Address - Phone:203-330-6790
Mailing Address - Fax:
Practice Address - Street 1:170 BENNETT STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605
Practice Address - Country:US
Practice Address - Phone:203-330-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health