Provider Demographics
NPI:1891379558
Name:SPEARS, TYSON SR (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:SPEARS
Suffix:SR
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6118 S MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-2929
Mailing Address - Country:US
Mailing Address - Phone:414-578-6625
Mailing Address - Fax:
Practice Address - Street 1:6118 S MERRILL AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-2929
Practice Address - Country:US
Practice Address - Phone:414-578-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7604-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional