Provider Demographics
NPI:1609355320
Name:TYSON, CHARLESZETTE
Entity Type:Individual
Prefix:
First Name:CHARLESZETTE
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 1:1020 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5246
Mailing Address - Country:US
Mailing Address - Phone:318-361-4482
Mailing Address - Fax:318-361-4880
Practice Address - Street 1:1020 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5246
Practice Address - Country:US
Practice Address - Phone:318-361-4482
Practice Address - Fax:318-361-4880
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator