Provider Demographics
NPI:1942519616
Name:TYSON, GWEN DALE (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:DALE
Last Name:TYSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 CHIPPENHAM CT
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9773
Mailing Address - Country:US
Mailing Address - Phone:252-327-0407
Mailing Address - Fax:662-325-3263
Practice Address - Street 1:57 TREVINO LN APT 11
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4443
Practice Address - Country:US
Practice Address - Phone:252-327-0407
Practice Address - Fax:662-325-3263
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7368101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor