Provider Demographics
NPI:1639665656
Name:QUEEN, TRYSTAN ROBERT (CMS)
Entity Type:Individual
Prefix:
First Name:TRYSTAN
Middle Name:ROBERT
Last Name:QUEEN
Suffix:
Gender:M
Credentials:CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 MILL RUN RD LOT 107
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-8809
Mailing Address - Country:US
Mailing Address - Phone:740-825-2764
Mailing Address - Fax:
Practice Address - Street 1:1071 TONG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:45612-1500
Practice Address - Country:US
Practice Address - Phone:740-634-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)