Provider Demographics
NPI:1548556939
Name:TYNAN, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:TYNAN
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 1:2 MAGEE ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-1836
Mailing Address - Country:US
Mailing Address - Phone:617-462-0265
Mailing Address - Fax:
Practice Address - Street 1:434 WARREN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1325
Practice Address - Country:US
Practice Address - Phone:617-541-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health