Provider Demographics
NPI:1639138639
Name:TYSON, MADALYN E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MADALYN
Middle Name:E
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16426 HAWFIELD WOODS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6108
Mailing Address - Country:US
Mailing Address - Phone:704-540-4291
Mailing Address - Fax:704-541-0319
Practice Address - Street 1:16426 HAWFIELD WOODS LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6108
Practice Address - Country:US
Practice Address - Phone:704-540-4291
Practice Address - Fax:704-541-0319
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1131103TB0200X, 103TC2200X, 103T00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000483Medicaid