Provider Demographics
NPI:1134853880
Name:TYSON, AMANDA BROOKE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 CRESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3512
Mailing Address - Country:US
Mailing Address - Phone:205-457-3768
Mailing Address - Fax:
Practice Address - Street 1:6236 AIRPARK DR STE A
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2988
Practice Address - Country:US
Practice Address - Phone:423-954-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-10
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health