Provider Demographics
NPI:1790763308
Name:TYSON, WILLIAM MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:TYSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16147 LANCASTER HWY STE 110
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4196
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:2006-01-04
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1169103T00000X, 103TC0700X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC461457000OtherMAGELLAN
NC04613OtherBCBS/NC