Provider Demographics
NPI:1568602829
Name:CROSS, TYRONE (LPT)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 GREEN CT
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-4415
Mailing Address - Country:US
Mailing Address - Phone:805-739-8706
Mailing Address - Fax:805-739-8738
Practice Address - Street 1:212 CARMEN LN STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7771
Practice Address - Country:US
Practice Address - Phone:805-739-8706
Practice Address - Fax:805-739-8738
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31258171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-1735271OtherCARES CRISIS RESIDENTIAL NORTH
CA1689762486OtherTELECARE CARES CRISIS RESIDENTIAL