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
StateLicense IDTaxonomies
MDLCA455101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLCA455OtherLICENSE CLINICAL ALCOHOL & DRUG COUNSELOR