Provider Demographics
NPI:1952078438
Name:TYSMAN, SARA JOY (LLPC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JOY
Last Name:TYSMAN
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13793 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8819
Mailing Address - Country:US
Mailing Address - Phone:616-638-0124
Mailing Address - Fax:
Practice Address - Street 1:21 W 16TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3320
Practice Address - Country:US
Practice Address - Phone:616-772-1733
Practice Address - Fax:616-879-0072
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health