Provider Demographics
NPI:1912219783
Name:TYSKIEWICZ, MICHAEL ANDREW (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:TYSKIEWICZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 STRAWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6930
Mailing Address - Country:US
Mailing Address - Phone:860-416-1293
Mailing Address - Fax:
Practice Address - Street 1:474 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-1149
Practice Address - Country:US
Practice Address - Phone:860-289-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical