Provider Demographics
NPI: | 1659798841 |
---|---|
Name: | FLEMING, TYRONE (LICENSE CLINICIAN) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | TYRONE |
Middle Name: | |
Last Name: | FLEMING |
Suffix: | |
Gender: | M |
Credentials: | LICENSE CLINICIAN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1630 RIVERWOOD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21221-2916 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-238-7587 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1630 RIVERWOOD RD |
Practice Address - Street 2: | |
Practice Address - City: | BALTIMORE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21221-2916 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-238-7587 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2014-03-25 |
Last Update Date: | 2014-03-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | LCA455 | 101YA0400X, 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | LCA455 | Other | LICENSE CLINICAL ALCOHOL & DRUG COUNSELOR |