Provider Demographics
NPI:1245879774
Name:TYSON, CHARLES GERMAINE (LCSW, BCD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:GERMAINE
Last Name:TYSON
Suffix:
Gender:M
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E GIRARD AVE # 604
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3311
Mailing Address - Country:US
Mailing Address - Phone:445-455-6045
Mailing Address - Fax:267-762-4374
Practice Address - Street 1:533 E GIRARD AVE # 604
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3311
Practice Address - Country:US
Practice Address - Phone:445-455-6045
Practice Address - Fax:267-762-4374
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0209931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical